THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rod@welchco.com


S U M M A R Y


DIARY: March 19, 2015 08:00 AM Thursday; Rod Welch

VA meeting Doctor Lee at VA Progress Notes for EGD procedure 141107.

1...Summary/Objective
2...Schedule Next EGD Dilation 150421 1300
3...Procedure Review Meetings Helpful Schedule Follow Up 140521
4...Ulceration Acid Burn LESV Fundoplication Failed Causing Hiatal Hernia
5...Fundoplication Failed Cause Hiatal Hernia Ulceration LESV Needs Surgical Repair
6...Surgical Repair Fundoplication Resolve Ulceration LESV and Hiatal Hernia in Stomach
7...Progress Notes Received EGD Dilation 141107 LESV Contracted 15mm
8...CT Test Esophagus and Coronary CTA
........Rapid regression of atherosclerosis: insights from the
........clinical and experimental literature
........Effects of Endurance Exercise Training on Plasma HDL
........Cholesterol Levels Depend on Levels of Triglycerides
........Exercise in Cardiovascular Disease Cardiovascular Effects of
........Exercise Training Molecular Mechanisms
........Coronary CTA Standard of Care Test Response to Treatment CVD
9...Progress Notes Meeting Today Gastroenterology Department VA Medical Center Sacramento
10...Fundoplication Very Low Failure Rate
....When Fundoplication Fails Redo?


..............
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CONTACTS 

SUBJECTS
EGD Dilation LESV 141107 Triamcinalone Injection Effective Swallowin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
1503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1503 -    ..
1504 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
1505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
150501 - Follow up ref SDS 40 0000. ref SDS 33 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
150502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
150503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
150504 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
150505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
150507 -  ..
1506 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1507 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1508 - Background                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
1509 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
150901 - Progress Notes have been missing longer than 4 months, from the VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
150902 - computer that stores patient medical records, for the EGD procedure on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150903 - 141107 0800. ref SDS 31 SY6M  Last night checked again and found they                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
150904 - are still missing, despite notice to the doctor on 141125 0942.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
150905 - ref SDS 32 OL6F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
150907 -  ..
150908 - On 150116 0813 met with Jessica at GI Clinic VA Medical Center in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
150909 - Sacramento, she has notified Doctor Lee that Progress Notes are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
150910 - missing for EGD Dilation on 141107, ref SDS 35 MX5I; later that day at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
150911 - 0922 Doctor Lee called and left voicemail message that his Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
150912 - Notes for the EGD Dilation procedure on 141107, are missing from VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
150913 - medical records computer system; he further said the missing Progresss                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150914 - Notes can be restored by scanning another source; he will have the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
150915 - records restored and submit notice to the patient when his Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
150916 - Notes can be downloaded using the Internet to access the VA computer                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
150917 - system. ref SDS 34 ZX6I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
150919 -  ..
150920 - On 150116 0813 at 0922 Doctor Lee called and left voicemail message                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
150921 - that his Progress Notes for the EGD Dilation procedure on 141107, are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
150922 - missing from VA medical records computer system; he further said the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
150923 - missing Progresss Notes can be restored from scanning another source;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
150924 - he will have the records restored and submit notice to the patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
150925 - when his Progress Notes can be downloaded using the Internet to access                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150926 - the VA computer system. ref SDS 34 ZX6I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
150928 -  ..
150929 - On 150120 1636 letter to Doctor Lee confirms understandings meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
150930 - with Jessica on 150116, and voicemail message from Doctor Lee later on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150931 - 150116, saying he will post Progress Notes for EGD Dilation procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
150932 - on 141107. ref SDS 36 VE95                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
150934 -  ..
150935 - On 150130 1609 called and left message for Jessica to follow up again                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
150936 - with Doctor Lee to post Progress Notes for EDG Dilation procedure at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
150937 - VA Sacramento Medical Center on 141107. ref SDS 37 MX5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
150939 -  ..
150940 - On 150211 1239 called EGD Department VA in Sacramento and talked to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
150941 - Jennifer; she coordinated with Jessica and recommended scheduling                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
150942 - meeting with Doctor Lee on preparing Progress Notes, ref SDS 39 6J9L,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
150943 - for the meeting with the doctor to perform EGD dilation procedure on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
150944 - 141107. ref SDS 31 K37G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
150945 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
150946 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
150948 -  ..
1510 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1511 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1512 - Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1513 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
151301 - Used c16 for notes on agenda issues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
151302 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
151303 -    1.  Swallowing continues without problems past 4 months since EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
151304 -        dilation on 141107 0800. ref SDS 31 7V6I  Triamcinalone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
151305 -        injection has been effective aiding swallowing, including                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
151306 -        previously difficult to swallow meats. ref SDS 31 6P6G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
151308 -         ..
151309 -        Hiking 11 miles per day aids digestion.  Large quantities of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
151310 -        orange juice (750 ML per day) combined with lemmon juice grape                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
151311 -        juice (about 100 ML each) and soft drink (Squirt or Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
151312 -        Pepper) have helped increase HDL from 30 to 70, shown in recent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
151313 -        lab on 150209 1012. ref SDS 38 RY6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
151315 -         ..
151316 -        Can this level of organge juice and lemon juice effect                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
151317 -        digestion system?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
151319 -  ..
151320 - Doctor Lee said orange juice, Lemmon and grape juice do not cause                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
151321 - harm to stomach and digestion system.  He advised that orange juice                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
151322 - and lemmon juice aid digestion process.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
151323 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
151324 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
151325 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
1514 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Schedule Next EGD Dilation 150421 1300 Improve Health Care Case Mana                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
4103 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
410401 -  ..
410402 - Schedule Next EGD Dilation 150421 1300                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
410403 - Procedure Review Meetings Helpful Schedule Follow Up 140521                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
410404 - 
410405 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
410406 - Agenda continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
410407 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
410408 -    2.  Schedule next EGD dilation OA 150420??? - approximately 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
410409 -        months after procedure on 141107.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
410411 -         ..
410412 -        Last time notified doctor need EGD dilation OA 4 months due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
410413 -        difficult swallowing.  This was evenntually scheduled 7 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
410414 -        after prior procedure.  Hoping for 6 months interval this time.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
410416 -  ..
410417 - After the meeting, we went to Jessica's office.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
410419 -  ..
410420 - Doctor Lee assisted Jessica in scheduling meetings based on his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
410421 - travel schedule.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
410423 -  ..
410424 - Scheduled next meeting for EGD Dilation procedure on 150421 1300                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
410426 -  ..
410427 - Doctor Lee said these consultation meetings are helpful, so we                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
410428 - scheduled a consultation meeting about 6 weeks after the procecure on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
410429 - 150421; it will be on 150521 0800.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
410431 -  ..
410432 - Doctor Lee advised that using this SDS record with customer's notebook                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
410433 - computer to guide the agenda for the meeting today, makes navigating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
410434 - patient's 10 year medical history efficient for working with complex                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
410435 - issues.  He asked how all the connections are created that instantly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
410436 - provide precise access to relevant details from among weeks, months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
410437 - and years of data?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
410439 -  ..
410440 - This aligns with Doctor Zipperstein's comments on SDS records saving                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
410441 - time and money improving medical case management, reported at Kaiser                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
410442 - on 940728 1943. ref SDS 1 0001   Month's later, Doctor Zipperstein                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
410443 - requested telephone conference using SDS records rather than schedule                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
410444 - meeting, reported on 940920 1132. ref SDS 2 5922                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
410446 -  ..
410447 - Doctor Sandhu in Primary Care at VA Clinic in Martinez reported using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
410448 - the Internet provides efficient communication to coordiate across VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
410449 - jurisdictions.  The doctor described navigating patient history in SDS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
410450 - records on the Internet is "pretty slick" saving time following heart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
410451 - surgery, reported on 100104 0930. ref SDS 8 YM7N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
410453 -  ..
410454 - Today, Doctor Lee submitted a new email address to confirm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
410455 - understandings for effective collaboration within the doctor patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
410456 - partnership....                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
410459 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
410460 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
410461 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
410462 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
410463 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
4105 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Acid Burn LESV Stricture Swallowing Problems Increased Because Fundo                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
5203 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
520401 -  ..
520402 - Ulceration Acid Burn LESV Fundoplication Failed Causing Hiatal Hernia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520403 - Fundoplication Failed Cause Hiatal Hernia Ulceration LESV Needs Surgical Repair                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520404 - Surgical Repair Fundoplication Resolve Ulceration LESV and Hiatal Hernia in Stomach                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520405 - 
520406 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520407 - Agenda continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
520408 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520409 -    3.  Nurses Procedure handwritten notes for EGD dilation proc on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520410 -        141107, say at the bottom in part...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520411 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520412 -            Bx'd ulcer site & esophagus at 29 cm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520414 -         ..
520415 -        Is this another way of saying the doctor biopsied the LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
520416 -        stricture, which is a routine part of EGD procedure, as listed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520417 -        in the record on 141107 0800. ref SDS 31 S36I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
520419 -         ..
520420 -        Is this a new issue?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520422 -         ..
520423 -        What was the result of the biopsy?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
520425 -  ..
520426 - Doctor Lee seemed to say there are 2 issues.  Dilation stretches the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520427 - LESV to enable normal swallowing.  However...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
520428 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520429 -        1.  Acid burn causes LESV to gradually constrict (increasing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520430 -            stricture) over weeks and months following dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
520431 -            procedure due to reflux from stomach digestion process.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520432 -            This causes rising swallowing problems.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520434 -             ..
520435 -        2.  Acid burn also causes ulceration at same LESV stricture                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520436 -            location due to reflux from stomach digestion process.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
520438 -  ..
520439 - The doctor showed traces of ulceration in photograph #4 taken during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520440 - EGD dilation on 141107. ref SDS 31 H19J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
520441 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520445 -  ..
520446 - Omeprazole is prescribed to prevent "acid burn" problems from stomach                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520447 - reflux by supplementing fundoplication.  Doctor Stewart constructed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520448 - fundoplication during Heller Myotomy surgery to treat achalasia on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520449 - 091216. ref SDS 7 KE9U (see Progress Notes received in the record a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
520450 - year later on 100928 0706, ref SDS 11 VK8F).  During the meeting at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
520451 - the VA Medical Center in San Francisco on 091030, Doctor Stewart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520452 - planned fundoplication to fold stomach tissue for preventing acid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
520453 - reflux flow from the stomach through LESV. ref SDS 6 OY64                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520455 -  ..
520456 - Doctor Lee explained that in the past year or so, fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520457 - surgically constructed 5 years ago, has unraveled.  He cited                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
520458 - photograph #4 as showing failed fundoplication, taken during EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520459 - dilation on 141107, listed in Progress Notes. ref SDS 31 H19J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520460 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520461 -              F:\05\00003\SM\CC\AGMJ\20141107-080000\EGD-11_07_2014-10_19-04-photograph.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
520463 -  ..
520464 - Doctor Lee placed this photograph next to another taken 3 or 4 years                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520465 - earlier, which seemed to show stomach tissue swirled or wrapped with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520466 - many wrinkles near the LESV.  He compared this with the picture taken                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520467 - during the EGD procedure on 141107, which seems much flatter, with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520468 - less swirls and wrikles.  This same comparison holds for photographic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520469 - records of EGD dilation just a year earlier on 131115. ref SDS 24 UP7F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
520471 -               ..
520472 -              F:\05\00003\SM\CC\AGMJ\20131115-080024\Welch_11-22-13-photograph.docx                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520474 -  ..
520475 - At that time on 131115, Progress Notes report "Fundoplication remains                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520476 - intact." ref SDS 24 JW4I  However, a year later on 141107, the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520477 - photograph seems markedly different.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520479 -  ..
520480 - The doctor advised that Findings of "ulceration" and "Hiatal hernia"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520481 - in Progress Notes on 140509, ref SDS 27 P396, correlates with failure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520482 - of fundoplication, as set out in Impressions from Progress Notes on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520483 - 140509 0900. ref SDS 27 I93F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520485 -  ..
520486 - This failure of the fundoplication system constructed by Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520487 - Stewart on 091216, now allows more acid reflux to pass through LESV,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520488 - which Omperazole alone cannot resolve.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520490 -  ..
520491 - Increased acid burn caused ulceration due to failure of fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520492 - may have begun OA time of EGD Dilation on 140509, when hiatical hernia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520493 - was first reported, ref SDS 27 P34O, that indicated loosening of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520494 - fundoplication. ref SDS 27 I93F  Progress Notes for prior procedure do                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
520495 - not report ulceration, hiatical hernia, nor loosening of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
520496 - fundoplication, reported in findings on 131115 0700. ref SDS 24 PY6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
520497 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520498 -            [On 150421 1210 EGD Dilation examination found ulceration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
520499 -            on LESV appears less severe, i.e., improved. ref SDS 43                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
520500 -            QQ7N  Progress Notes found ulcerations regressing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
520501 -            (improving) to mere erosions. ref SDS 44 PXXY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
520503 -  ..
520504 - Doctor Lee explained that fundoplication was initially considered very                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520505 - successful, but, like the instant case, eventual failures have been                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520506 - reported in the medical literature.  After the meeting today, research                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520507 - found June 2005 NIH article in "Anals of Surgery" and titled "When                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520508 - Fundoplication Fails Redo?" ref SDS 0 RI3M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
520510 -  ..
520511 - Patient requested Doctor Lee refer findings to Doctor Stewart from the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520512 - procedure on 141107, showing fundolplication issues may be causing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520513 - swallowing problems, per above. ref SDS 0 N46G  Patient can inquire on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520514 - referral about new procedures to correct the problem, including                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520515 - possibly re-doing fundoplication in order to reduce acid reflux to a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520516 - level that avoids continung ulceration and constriction of LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520517 - causing swallowing problems that require repeated EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
520518 - procedures.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520519 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520520 -            [On 150420 1752 letter submits agenda for meeting on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520521 -            150421, to review referral to Doctor Stewart to remedy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
520522 -            failed fundoplication. ref SDS 42 WL4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
520524 -             ..
520525 -            [On 150421 1210 Progress Notes for EGD Dilation procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
520526 -            recommendations cite referral to San Francisco Surgical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520527 -            Clinic for consideration of repeat fundoplication.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
520528 -            ref SDS 44 KT69                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520530 -             ..
520531 -            [On 150514 0130 letter to Doctor Lee requests file Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
520532 -            Notes for EGD Dilation today, and make referral to Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520533 -            Stewart, to prepare for meeting with Doctor Lee scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520534 -            on 150521. ref SDS 45 K37G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520536 -             ..
520537 -            [On 150514 0130 at 1326 received call from VA Medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520538 -            Center in San Francisco and scheduled meeting with Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520539 -            Stewart in General Surgery to review "redo" fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520540 -            to recover from surgery failure in order to prevent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
520541 -            recurrence and compounding of ulcerations on LESV that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
520542 -            worsen achalasia swallowing problems. ref SDS 45 US53                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520543 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520544 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520545 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520546 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
5206 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Progress Notes Received EGD Dilation 141107 LESV Contracted 15mm Bec                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
6103 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
610401 -  ..
610402 - Progress Notes Received EGD Dilation 141107 LESV Contracted 15mm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610403 - 
610404 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610405 - Agenda continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610406 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610407 -    4.  Progress Notes for meeting on 141107 0800. ref SDS 31 CY7I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610408 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610409 -        On 150116 0813 at 0922 Doctor Lee called and left voicemail                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610410 -        message that his Progress Notes for the EGD Dilation procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610411 -        on 141107, are missing from VA medical records computer system;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610412 -        he further said the missing Progresss Notes can be restored                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610413 -        from scanning another source; he will have the records restored                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610414 -        and submit notice to the patient when his Progress Notes can be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610415 -        downloaded using the Internet to access the VA computer system.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610416 -        ref SDS 34 ZX6I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
610418 -  ..
610419 - During the meeting today, Doctor Lee showed his Progress Notes for the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610420 - prior EGD Dilation procedure on 141107.  He said they were completed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610421 - and posted yesterday, and so should be available for the patient to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
610422 - download within a few days.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610424 -  ..
610425 - The doctor noted Progress Notes report LESV contracted from 18 mm to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610426 - 16.5 mm.  There was brief discussion that 1.5 mm seems conflicting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610427 - with record of increased swallowing problems during the prior period,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610428 - cited in requests to the VA for early dilation, e.g., on 140810 1839,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610429 - ref SDS 29 W83K, and again, 141103 2152. ref SDS 30 K37G  We reviewed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610430 - patient record of post-procedure meeting on 141107, showing Doctor Lee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610431 - seemed to advise that LESV contracted 3 mm from 18 mm down to 15 mm,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610432 - consistent with severe swallowing problems experienced prior to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610433 - dilation back to 18 mm. ref SDS 31 6P6G  Contraction to 15 mm on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610434 - 141107, appears consistent with patient history of prior LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
610435 - dilations when triamcinolone was not injected, as occurred on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
610436 - 140509...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610438 -                 ..
610439 -                LESV Dilated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610440 -                Date   from - to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610441 -                141107   15   18.....triamcinolone.... ref SDS 31 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610442 -                140509   16.5 18...................... ref SDS 27 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610443 -                131115   16.5 18.....triamcinolone.... ref SDS 24 RZ45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610444 -                130416   18   18.....triamcinolone.... ref SDS 23 Y850                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610445 -                130110   15   18.....triamcinolone.... ref SDS 20 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610446 -                120925   15   18.....triamcinolone.... ref SDS 18 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610447 -                120322   16.5 18...................... ref SDS 17 516N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610448 -                111115   16.5 18...................... ref SDS 16 IR57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610449 -                110819   15   16.5...triamcinolone.... ref SDS 15 J978                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610450 -                110429   13   16.5...triamcinolone.... ref SDS 14 U23I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610451 -                110218   11   14.....triamcinolone.... ref SDS 13 AA5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610452 -                101210   11   14...................... ref SDS 12 H347                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610453 -                100827   11   15...................... ref SDS 10 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610454 -                100305   11   15...................... ref SDS 9 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
610455 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610456 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
6105 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
CT Test Esophagus Recurrance Achalasia Hiatal Hernia Referral Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
7403 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
740401 -  ..
740402 - CT Test Esophagus and Coronary CTA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
740403 - 
740404 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
740405 -    5.  CT test evaluate esophagus and adding coronary CTA with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
740406 -        calcium score.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
740408 -  ..
740409 - Previously, on 130108, Doctor Lee ordered a CT test, ref SDS 19 8H4K,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
740410 - to evaluate recovery from achalasia swallowing problems.  Earlier on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
740411 - 051202, Doctor Lee diagnosed achalasia noting a large bulge in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
740412 - esophagus caused by failure of LESV function to enable normal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
740413 - swallowing, ref SDS 4 5B5K, shown in prior CT testing on 050714 1000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
740414 - ref SDS 3 2I9J  On 091216, Doctor Stewart performed Heller Myotomy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
740415 - surgery at VA Medical Center in San Francisco, intended to resolve                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
740416 - achalasia. ref SDS 7 KE9U                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
740418 -  ..
740419 - On 130110, Doctor Lee performed EGD Dilation procedure, ref SDS 20                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
740420 - 134H, continuing supplemental care beginning after surgery, as                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
740421 - follows...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
740422 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
740423 -                LESV Dilated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
740424 -                Date   from - to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
740425 -                130110   15   18.....triamcinolone.... ref SDS 20 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
740426 -                120925   15   18.....triamcinolone.... ref SDS 18 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
740427 -                120322   16.5 18...................... ref SDS 17 516N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
740428 -                111115   16.5 18...................... ref SDS 16 IR57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
740429 -                110819   15   16.5...triamcinolone.... ref SDS 15 J978                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
740430 -                110429   13   16.5...triamcinolone.... ref SDS 14 U23I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
740431 -                110218   11   14.....triamcinolone.... ref SDS 13 AA5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
740432 -                101210   11   14...................... ref SDS 12 H347                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
740433 -                100827   11   15...................... ref SDS 10 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
740434 -                100305   11   15...................... ref SDS 9 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
740436 -  ..
740437 - On 130117 VA performed CT barrium swallow test ordered by Doctor Lee.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
740438 - ref SDS 21 LM8K  This test showed the esophagus had fully recovered on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
740439 - 130117. ref SDS 21 OH6G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
740441 -  ..
740442 - This favorable test result was reviewed by Doctor Stewart during a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
740443 - meeting at the VA in San Francisco on 130122 1330. ref SDS 22 03H6  At                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
740444 - that time, Doctor Stewart was pleased to see full recovery,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
740445 - ref SDS 22 UM5L, 4 years after she performed Heller Myotomy surgery                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
740446 - on 091216, to correct grossly deformed esophagus and thereby relieve                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
740447 - severe swallowing problems.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
740449 -  ..
740450 - We discussed today, ordering a follow up CT test of the esophagus for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
740451 - recovery from increased swallowing problems, per above. ref SDS 0 6P9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
740453 -  ..
740454 - Doctor Lee will include in his letter to Doctor Stewart consideration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
740455 - on ordering follow up CT test of the esophagus to evaluate recovery of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
740456 - achalasia, along with review of correcting fundoplication issues, per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
740457 - above. ref SDS 0 JQ5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
740459 -  ..
740460 - Another CT test could include the chest and lower abdomen to check for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
740461 - regression of atherosclerotic plaques.  Doctor Stewart works with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
740462 - Doctor Elaine Tseng, attending physician for CABG +4 surgery performed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
740463 - on 091022. ref SDS 5 PQWU  Doctor Tseng may be positioned to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
740464 - collaborate on ordering coronary CTA with calcium score to assess                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
740465 - results from patient hiking 8,500 miles, summarized in case study on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
740466 - 140101 0600. ref SDS 26 XY4M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
740468 -  ..
740469 - Hiking 11 miles per day has increased by 130% HDL 30 to HDL 70, over                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
740470 - the past 4 years shown in most recent labs on 150209 1012. ref SDS 38                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
740471 - W25L  Research on 131125, indicates that exercise also increases EPCs,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
740472 - and this combination of elevated HDL and EPCs can "rapidly" repair                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
740473 - damage to endothelial lining of blood vessels, commonly called                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
740474 - "atherosclerotic plaques." ref SDS 25 HG90                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
740476 -  ..
740477 - If plaques are no longer evident in coronary CTA this may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
740478 - justify reducing prescribed care hiking 300 miles per month, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
740479 - taking statin medications.  Reducing level of care would save                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
740480 - considerable time and money, and also reduce onerous side effects of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
740481 - daily medications.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
740483 -  ..
740484 - Doctor Lee requested research on regressing atherosclerosis and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
740485 - testing with coronary CTA radiology.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
740486 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
740487 -            [On 150323 1926 letter to Doctor Lee provided access to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
740488 -            this record listing requested research on coronary CTA.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
740489 -            ref SDS 41 WV3H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
740491 -  ..
740492 - Following links present extracted research with narrative correlating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
740493 - with patient history, and further linked to original articles...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
740494 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
740495 -    1.  On 131125, research indicated "rapid" regression of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
740496 -        atherosclerosis occurs with elevated HDL and EPCs (Endothelial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
740497 -        Progenitor Cells). ref SDS 25 6S7F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
740499 -         ..
740500 -        Rapid regression of atherosclerosis: insights from the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
740501 -        clinical and experimental literature                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
740502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
740503 -              http://www.nature.com/nrcardio/journal/v5/n2/full/ncpcardio1086.html                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
740505 -         ..
740506 -        Nature Clinical Practice Cardiovascular Medicine (2008) 5,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
740507 -        91-102                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
740508 -        doi:10.1038/ncpcardio1086                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
740509 -        Received 7 March 2007 | Accepted 17 October 2007                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
740511 -         ..
740512 -        Kevin Jon Williams*, Jonathan E Feig and Edward A Fisher*                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
740513 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
740515 -         ..
740516 -    2.  On 131125, research indicated endurance exercise increases HDL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
740517 -        and lowers triglycerides. ref SDS 25 U44L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
740519 -         ..
740520 -        American Heart Association                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
740521 -        Arteriosclerosis, Thrombosis, and Vascular Biology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
740523 -         ..
740524 -        Effects of Endurance Exercise Training on Plasma HDL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
740525 -        Cholesterol Levels Depend on Levels of Triglycerides                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
740527 -         ..
740528 -        Received January 29, 2001.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
740529 -        Accepted April 6, 2001.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
740530 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
740531 -              http://atvb.ahajournals.org/content/21/7/1226.full                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
740532 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
740534 -         ..
740535 -    3.  On 131125, research indicated endurance exercise increases EPCs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
740536 -        required along with raising HDL for regression of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
740537 -        atherosclerosis plaques. ref SDS 25 8X4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
740539 -         ..
740540 -        American Heart Association                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
740542 -         ..
740543 -        Exercise in Cardiovascular Disease Cardiovascular Effects of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
740544 -        Exercise Training Molecular Mechanisms                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
740545 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
740546 -              http://circ.ahajournals.org/content/122/12/1221.full#sec-34                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
740548 -         ..
740549 -        Stephan Gielen, MD; Gerhard Schuler, MD; Volker Adams, PhD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
740551 -         ..
740552 -        Coronary CTA Standard of Care Test Response to Treatment CVD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
740554 -         ..
740555 -    4.  On 140519 meeting with Doctor Alba at VA Medical Center in San                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
740556 -        Francisco reviewed research sources on standard of care testing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
740557 -        response to treatment to reduce risk of CVD, using coronary CTA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
740558 -        with calcium score. ref SDS 28 OF7N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
740560 -         ..
740561 -        See in particular para 4...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
740563 -         ..
740564 -        Regression of coronary plaque after coronary artery bypass graft                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
740565 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
740566 -              http://www.sciencedirect.com/science/article/pii/S1878540912000035                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
740567 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
740568 -        ...and saying in part...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
740570 -         ..
740571 -        Three years after treatment, 64-MDCT showed mild stenosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
740572 -        and a regression of plaque in the LMT. The mean density of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
740573 -        the plaque was 73.1 HU (intermediate plaque) [...before                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
740574 -        CABG and 32.4 after CABG; plaque size reduced from 20.7 to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
740575 -        4.26...]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
740576 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
740577 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
740578 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
7406 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Progress Notes Meeting 150319 GI Clinic Gastroenterology Department                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
8403 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
840401 -  ..
840402 - Progress Notes Meeting Today Gastroenterology Department VA Medical Center Sacramento                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
840403 - 
840404 - Follow up ref SDS 31 CY7I, ref SDS 27 CY7I, ref SDS 24 CY7I.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
840406 -  ..
840407 - VA website is at...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
840408 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
840409 -              https://www.myhealth.va.gov/mhv-portal-web/anonymous.portal?_nfpb=true&_nfto=false&_pageLabel=mhvHome                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
840410 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
840416 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
840418 -  ..
840419 - On 150418 found Progress Notes for meeting on 150319...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
840421 -               ..
840422 -              F:\05\00003\SM\CC\AGMJ\20150319-080000\mhv_20150324_0607.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
840424 -               ..
840425 -              F:\05\00441\CG\GG\HMC\20150319-080000\mhv_20150324_0607.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
840427 -               ..
840428 -              F:\05\00441\SM\BGMC\20150319-080000\mhv_20150324_0607.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
840430 -         ..
840431 -    1.  LOCAL TITLE: Gastroenterology Attending F/U Note 60127                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
840432 -        STANDARD TITLE: GASTROENTEROLOGY ATTENDING NOTE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
840433 -        DATE OF NOTE: MAR 19, 2015@08:00 ENTRY DATE: MAR 19, 2015@14:47                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
840434 -        AUTHOR: LEE,RANDALL E EXP COSIGNER:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
840435 -        URGENCY: STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
840437 -         ..
840438 -    2.  fu 1390582 reviewed prior egd report, requests query to dr.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
840439 -        stewart for consideration of repeat fundopliation discussed his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
840440 -        cad, requests ccta schedule routine egd & dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
840442 -  ..
840443 - Why is there no reference to prior Progress Notes on 140509, reporting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
840444 - hiatal hernia caused by failed fundoplication, ref SDS 27 I93F, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
840445 - further discussed during the meeting today, per above? ref SDS 0 KN6F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
840447 -  ..
840448 - Progress Notes for meeting on 150319 continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
840449 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
840450 -    3.  /es/ Randall E. Lee, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
840451 -        Staff Physician, Gastroenterology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
840452 -        Signed: 03/19/2015 14:48                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
840453 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
840454 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
840455 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
840456 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
8405 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Fundoplication Very Low 3% Failure Rate Research Internet NIH Annals                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
9903 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
9904 - 2213                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
990501 -  ..
990502 - Fundoplication Very Low Failure Rate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990503 - 
990504 - After the meeting this morning with Doctor Lee, research found article                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990505 - on frequency of fundoplication failure, and indicating laparoscopic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990506 - surgery can successfully "redo" fundoplication so that acid reflux is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990507 - controlled with minimal medication, as planned during the meeting at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990508 - the VA on 091030 0810, ref SDS 6 OY69                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
990509 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990510 -    PMC                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990511 -    US National Library of Medicine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990512 -    National Institutes of Health                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
990514 -     ..
990515 -    Annals of Surgery                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990516 -    A Monthly Review of Surgical Science Since 1885                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990518 -     ..
990519 -    Ann Surg. 2005 Jun; 241(6): 861871.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
990520 -    PMCID:  PMC1357166                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990521 -    doi:  10.1097/01.sla.0000165198.29398.4b                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
990523 -     ..
990524 -    When Fundoplication Fails Redo?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990525 -    
990526 -    C Daniel Smith, MD,* David A. McClusky, MD,* Murad Abu Rajad, MD,* Andrew B.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990527 -    Lederman, MD,  and John G. Hunter, MD!                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
990528 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990529 -              http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990531 -         ..
990532 -    1.  Abstract                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990533 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990534 -        1.  Objective:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990535 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990536 -            The largest series in the literature dealing with redo                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990537 -            fundoplication was presented and published in 1999 and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990538 -            included 100 patients.  Herein we update this initial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
990539 -            series of 100, with 207 additional patients who have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990540 -            undergone redo fundoplication (n = 307).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990542 -             ..
990543 -        2.  Summary Background Data:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990544 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990545 -            Increasing numbers of patients are failing esophagogastric                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990546 -            fundoplication and requiring redo procedures.  Data                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
990547 -            regarding the nature of these failures have been scant.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990548 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990550 -             ..
990551 -        3.  Methods:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990552 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990553 -            Data on all patients undergoing foregut surgery are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
990554 -            collected prospectively.  Between 1991 and 2004, 307                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990555 -            patients underwent redo fundoplication for the management                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990556 -            of anatomic complications or recurrent GERD.  Statistical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990557 -            analysis was performed with multiple 2 and Mann-Whitney U                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990558 -            analyses, as well as ANOVA.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990559 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990561 -             ..
990562 -        4.  Results:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990563 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990564 -            Between 1991 and 2004, 1892 patients underwent primary                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990565 -            fundoplication for GERD (1734) or paraesophageal hernia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990566 -            (158).  Of these, 54 required redo fundoplication (2.8%).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990567 -            The majority of failures (73%) were managed within 2 years                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990568 -            of the initial operation (P = 0.0001). The mechanism of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990569 -            failure was transdiaphragmatic wrap herniation in 33 of 54                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990570 -            (61%).  In the 231 patients who underwent fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990571 -            elsewhere, 109 had transdiaphragmatic herniation (47%, P =                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990572 -            NS). In this group of 285 patients, 22 (8%) required                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990573 -            another redo (P = NS).  The majority of the procedures were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990574 -            initiated laparoscopically (240/307, 78%), with 20                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
990575 -            converted (8%). Overall mortality was 0.3%.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990577 -             ..
990578 -        5.  Conclusions:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
990579 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990580 -            Failure of fundoplication is unusual in experienced hands.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990581 -            Most are managed within 2 years of the initial operation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990582 -            Wrap herniation has now become the most common mechanism of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990583 -            failure requiring redo.  Redo fundoplication was successful                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990584 -            in 93% of patients, and most could be safely handled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990585 -            laparoscopically.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
990586 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990588 -         ..
990589 -    2.  Since its introduction in 1991,1 laparoscopic, ref SDS 24 F37N,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
990590 -        Nissen (360 degree) fundoplication has become the most widely                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990591 -        applied antireflux procedure accounting for 87 of every                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990592 -        100,000 hospital discharges in 1999, according to the National                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990593 -        Inpatient Sample.2 This represents a near 8-fold increase for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990594 -        this procedure over a 10-year period.  The best outcomes with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990595 -        5-year or longer follow-up after Nissen fundoplication report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990596 -        patient satisfactions of 86% to 96%, making the laparoscopic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990597 -        Nissen fundoplication the gold standard for antireflux                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
990598 -        procedures.38                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990600 -         ..
990601 -    3.  Laparoscopic fundoplication has recently been called into                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
990602 -        question.9-11 The rate of failure following fundoplication for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990603 -        gastroesophageal reflux disease (GERD) varies from 2%-30%,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990604 -        depending on how "failure" is defined; for example, failure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990605 -        requiring resumption of medical therapy versus failure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
990606 -        requiring reoperation.  Failure following Nissen fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990607 -        for paraesophageal hernia also ranges from 7%-33%, depending on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990608 -        whether failure is defined symptomatically or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990609 -        anatomically.12-14 In select cases, fundoplication failure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990610 -        requires revisional fundoplication (redo).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990612 -         ..
990613 -    4.  In 1996, we reported our experience with redo fundoplication in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990614 -        100 consecutive patients, detailing the pattern of failure and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990615 -        outcomes with redo fundoplication.15 Herein, we detail our                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990616 -        updated experience with over 300 consecutive redo                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
990617 -        fundoplications.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
990619 -         ..
990620 -    5.  MATERIALS AND METHODS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
990621 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990622 -        1.  Patients                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990623 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990624 -            1.  The institution's institutional review board approved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990625 -                this study.  Data on all foregut patients undergoing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990626 -                surgery are collected prospectively and maintained in a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990627 -                computer database (Microsoft Access, Microsoft Corp,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990628 -                Seattle, WA).  Details on preoperative presentation and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990629 -                symptoms, results from objective testing (typically,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990630 -                barium swallow, esophagogastroduodenoscopy, ambulatory                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990631 -                esophageal pH testing, esophageal motility, and gastric                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990632 -                emptying), operative findings including                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990633 -                surgeon-documented mechanism of failure (herniated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990634 -                fundoplication, disrupted fundoplication, slipped                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
990635 -                fundoplication, crural stenosis/tight wrap, misplaced                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990636 -                fundoplication, and twisted fundoplication), and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990637 -                postoperative course. When more than 1 failure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
990638 -                mechanism was identified intraoperatively, the most                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990639 -                prominent or causative mechanism was recorded as the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990640 -                mechanism of failure (eg, fundoplication herniation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990641 -                accompanied by fundoplication disruption was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
990642 -                categorized as a herniated fundoplication).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
990644 -                 ..
990645 -            2.  Postoperative symptom assessment was performed 1 month                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990646 -                after surgery and annually thereafter.  Symptoms of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990647 -                heartburn, dysphagia, and chest pain were assessed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990648 -                using a 5-point scale (0, none; 1, mild; 2, moderate;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990649 -                3, severe; 4, intolerable).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
990651 -                 ..
990652 -            3.  Revisional surgery (redo fundoplication) is offered to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990653 -                patients who have persistent, recurrent, or new foregut                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990654 -                symptoms (heartburn, dysphagia, chest pain,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
990655 -                regurgitation, asthma, hoarseness, chronic cough, or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990656 -                laryngitis) and confirmed physiologic abnormalities or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990657 -                a definable anatomic defect.  Potential candidates for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990658 -                redo fundoplication are evaluated for anatomic and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990659 -                physiologic evidence of failure by selective use of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990660 -                barium swallow, upper endoscopy, esophageal motility,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990661 -                esophageal pH testing, and gastric emptying study.  For                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990662 -                this study, preoperative diagnoses were assigned based                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990663 -                upon these objective evaluations, and all types of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990664 -                fundoplication (partial or complete) and operative                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990665 -                approaches (open, laparoscopic, converted, or thoracic)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990666 -                were included.  Patients were excluded if their initial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990667 -                operation was for the diagnosis of achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
990669 -                 ..
990670 -            4.  From October 1, 1991, to April 1, 2004, 1892 patients                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990671 -                underwent primary fundoplication at Emory for GERD (n =                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990672 -                1734) or paraesophageal hernia repair (n = 158) (Fig.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990673 -                1). Of these, 54 patients required redo fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990674 -                (2.8%).  For purposes of comparison and data analysis,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990675 -                these 54 patients have been grouped together (internal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990676 -                primary fundoplication group, n = 54).  During this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990677 -                same time period, 231 patients underwent fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990678 -                elsewhere and subsequently underwent redo                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
990679 -                fundoplication at Emory.  All patients who underwent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990680 -                any redo fundoplication, either first redo or multiple                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990681 -                redos, prior to referral to Emory are grouped (external                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990682 -                fundoplication group, n = 231).  From the combined                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990683 -                group of 285 patients (54 Emory patients and 231                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990684 -                external patients), more than 1 redo fundoplication was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990685 -                necessary in 22 patients (multiple redos group, n = 22)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990686 -                bringing the total number of redo fundoplications                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
990687 -                performed during this time period to 307 redos in 285                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990688 -                patients. Stratified by number of redos, 241 patients                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990689 -                underwent 1 redo, 59 underwent 2 redos, 6 underwent 3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990690 -                redos, and 1 underwent 4 redo fundoplications (Fig. 2).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990691 -                Again, for comparing preoperative presentation and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990692 -                operative findings for the first redos, those referred                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990693 -                after failure of primary fundoplication externally are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990694 -                grouped (external primary fundoplication group, n =                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990695 -                187).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990697 -                 ..
990698 -                FIGURE 1. Antireflux surgery at Emory from 1992 through 2004.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
990699 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990700 -                      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/figure/f1-3/                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
990702 -                 ..
990703 -                FIGURE 2. Breakdown of patients undergoing redo fundoplication.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
990704 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990705 -                      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/figure/f2-3/                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
990706 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990708 -                 ..
990709 -            5.  Follow-up                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
990710 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990711 -                1.  For the past 10 years, a full-time research nurse                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990712 -                    has been maintaining Emory's foregut database.  In                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990713 -                    addition to collecting data from office visits, the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990714 -                    research nurse also contacts patients every 23                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990715 -                    years by phone or mail and has them complete a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990716 -                    follow-up questionnaire. When a patient cannot be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990717 -                    found through the contact information maintained in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990718 -                    the database, an Internet search for the patient's                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990719 -                    contact information is conducted. This is a paid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990720 -                    service and claims that if an individual cannot be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990721 -                    found, they do not want to be found.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
990723 -                     ..
990724 -                2.  With this follow-up strategy, follow-up information                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990725 -                    is available on 88% of the study group (269/307).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990726 -                    However, over time the rate of follow-up decreases                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990727 -                    significantly (Fig. 3). One year or longer                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
990728 -                    follow-up data are only available on 54% of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
990729 -                    patients who are more than 1 year postoperative                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990730 -                    (150/278).  Median follow-up for the overall group                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990731 -                    is 1.2 years (range, 93042 days).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990733 -                     ..
990734 -                    FIGURE 3. Number of patients with follow-up data available by year.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990735 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990736 -                          http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/figure/f3-3/                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
990737 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990739 -                 ..
990740 -            6.  Statistics                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
990741 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990742 -                Statistical analysis was performed with multiple 2 and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990743 -                Mann-Whitney U analyses, as well as ANOVA.  Comparisons                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990744 -                of preoperative and postoperative data were made with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990745 -                the Wilcoxon signed-rank test. Statistical significance                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990746 -                was set at P < 0.05 for each symptom.
990748 -         ..
990749 -    6.  RESULTS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
990750 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990751 -        1.  Redo Clinical Presentation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990752 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990753 -            1.  Internal Primary Fundoplication (n = 54) Fifty-four                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990754 -                patients undergoing redo fundoplication had their                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
990755 -                primary fundoplication at Emory for either                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
990756 -                paraesophageal hernia (n = 10) or GERD (n = 40).  In                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990757 -                this group, very few patients were experiencing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
990758 -                dysphagia (n = 8) or chest pain (n = 0) before their                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990759 -                first fundoplication (Table 1).  While the new onset of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990760 -                chest pain following fundoplication occurred in several                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990761 -                patients (n = 5), the most common new clinical finding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990762 -                in patients requiring redo fundoplication was dysphagia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990763 -                (15% prior to first fundoplication versus 56% prior to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990764 -                redo; P < 0.05).
990766 -                 ..
990767 -                TABLE 1. Clinical Presentation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
990768 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990769 -                      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/table/t1-3/                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
990771 -                 ..
990772 -            2.  The majority of failures were managed within 2 years of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990773 -                the initial operation (73%).  Five patients underwent a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990774 -                redo within 14 days after their primary                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
990775 -                fundoplication. All 5 suffered immediate postoperative                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990776 -                nausea and retching followed by severe dysphagia, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990777 -                all underwent an immediate contrast swallow, which                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990778 -                revealed wrap herniation above the diaphragm. All were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990779 -                immediately returned to the operating room for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
990780 -                reduction and repair of the hernia.  None of these                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990781 -                patients went on to require another redo                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
990782 -                fundoplication.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
990784 -                 ..
990785 -            3.  External Fundoplication (n = 231)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
990786 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990787 -                The majority of patients in this series undergoing redo                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990788 -                fundoplication were referred from externally (n = 231)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990789 -                after fundoplication for GERD (n = 198) or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
990790 -                paraesophageal hernia (n = 31). Forty-two patients                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990791 -                underwent 1 redo externally before referral, and 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990792 -                underwent 2 redos prior to referral (Fig. 2).  Results                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990793 -                in patients undergoing multiple redos are detailed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990794 -                later in the Multiple Redos section.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990796 -                 ..
990797 -            4.  Presenting findings are detailed in Table 1 Compared                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990798 -                with the internal primary fundoplication group,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
990799 -                patients referred for redo fundoplication were more                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990800 -                likely to have recurrent GERD as the clinical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
990801 -                presentation for redo (60% of external versus 48%                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
990802 -                internal primary fundoplication).  Patients referred                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990803 -                were more likely to have a delayed presentation for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990804 -                redo fundoplication, with 66% of patients in this group                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990805 -                having their redo fundoplication within 2 years of the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990806 -                primary operation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990808 -             ..
990809 -        2.  Patterns of Failure: Operative Findings                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990810 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990811 -            1.  Internal Primary Redos (n = 54)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
990812 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990813 -                In the 54 patients from Emory undergoing redo                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
990814 -                fundoplication, 52 were initiated laparoscopically                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990815 -                (96%).  Two were converted to open procedures due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990816 -                dense adhesions in the operative field, resulting in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990817 -                50/54 patients successfully undergoing laparoscopic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990818 -                revisions (93%).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990820 -                 ..
990821 -            2.  The reasons for failure as documented in operative                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990822 -                reports are detailed in Table 2.  The majority of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
990823 -                failures fell into the categories of fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990824 -                herniation, fundoplication disruption, slipped                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
990825 -                fundoplication or tight wrap/crural stenosis.  Only 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990826 -                failures were felt to be due to technical errors during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990827 -                the first operation (1 twisted wrap and 1 misplaced                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990828 -                wrap).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990830 -                 ..
990831 -                TABLE 2. Patterns of Failure (%)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990832 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990833 -                      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/table/t2-3/                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
990835 -                 ..
990836 -            3.  Eleven intraoperative complication were encountered in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990837 -                9 patients (17%) (Table 3).  Two of the 4 patients                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990838 -                undergoing an open redo experienced an intraoperative                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990839 -                complication, and in both cases this was gastric                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990840 -                perforation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
990842 -                 ..
990843 -                TABLE 3. Intraoperative Perforations (No.)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
990844 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990845 -                      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/table/t3-3/                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
990847 -             ..
990848 -        3.  External Primary Fundoplication (n = 187)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990849 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990850 -            1.  A laparoscopic approach was chosen for the 151 patients                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990851 -                whose initial fundoplication was performed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
990852 -                laparoscopically.  Thirteen of these 151 laparoscopic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990853 -                redos were converted to open procedures (8.6%). In 9 of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990854 -                the 27 patients whose initial operation was open, the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990855 -                redo was initiated laparoscopically, with 2 of these 9                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990856 -                being converted to open procedures (conversion rate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990857 -                when first operation open, 22%). In this group, 77% of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990858 -                the redos were successfully completed laparoscopically,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990859 -                and the overall conversion rate was 9.4% (15/160).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990860 -                Combining this with the internal primary fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990861 -                group, the overall conversion rate was 8% (20/240).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990862 -                All conversions were for dense adhesions at the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
990863 -                operative site.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
990865 -                 ..
990866 -            2.  As in the internal primary group, the most common                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
990867 -                pattern of failure was fundoplication herniation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
990868 -                There were also comparable other reasons for failure in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990869 -                all categories except for misplaced fundoplications.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990870 -                Significantly more patients who underwent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
990871 -                fundoplication externally were found to have a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
990872 -                misplaced wrap (2% internal versus 11% external; P<
990873 -                0.05).  Figure 4 depicts the most common configuration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990874 -                of the misplaced fundoplication, using the gastric body                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990875 -                for the wrap instead of the fundus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990877 -                 ..
990878 -                FIGURE 4. Most common configuration of a misplaced wrap.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
990879 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990880 -                      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/figure/f4-3/                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
990882 -                 ..
990883 -            3.  Forty-three operative complications occurred in 39                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990884 -                patients undergoing their first redo.  Intraoperative                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990885 -                complications were more likely when the procedure was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990886 -                converted from laparoscopic to open than for open or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990887 -                laparoscopic alone (62% versus 17% and 17%; P < 0.05)
990888 -                and in the overall group of 307 redos, gastric                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
990889 -                perforation was the most common intraoperative                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
990890 -                complication (Table 3).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990892 -             ..
990893 -        4.  Immediate Postoperative Outcomes (Total Group, n = 307)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990894 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990895 -            Postoperatively, 48 patients experienced 59 complications (14.7%).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
990896 -            Complications are detailed in Table 4. Complications were more common in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990897 -            patients undergoing open redo fundoplication compared with those undergoing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990898 -            laparoscopic redo (32.5% versus 10%, P < 0.05). Forty percent of those who
990899 -            underwent conversion from laparoscopic to open redo suffered a complication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990900 -            versus only 13% of those who had their operation completed laparoscopically                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990901 -            (8/20 versus 40/287; P < 0.05). One patient died of sepsis and multisystem
990902 -            organ failure from pneumonia after an open redo. There was a trend toward an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
990903 -            increased complication rate as patients underwent multiple redos (see section                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
990904 -            below on Multiple Redos).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990906 -             ..
990907 -            TABLE 4. Complications Following Redo Fundoplication, No. (%)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
990908 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990909 -                  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/table/t4-3/                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990910 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990912 -             ..
990913 -        5.  Long-term Outcomes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
990914 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990915 -            1.  Symptom Response                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990916 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990917 -                1.  All patients underwent pre- and postoperative symptom                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
990918 -                    assessment for heartburn, dysphagia, and chest pain.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
990919 -                    In addition, use and dosage of antisecretory                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990920 -                    medications were recorded, as well as the need for any                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
990921 -                    postoperative interventions (EGD with dilation or more                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
990922 -                    surgery related to foregut problems).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
990924 -                     ..
990925 -                2.  Between 73% and 89% of patients reported their                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990926 -                    postoperative symptoms of heartburn, dysphagia, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990927 -                    chest pain to be absent or mild.  Similarly, only 3%8%                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
990928 -                    of patients reported their symptoms postoperatively to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
990929 -                    be severe, and no patients rated their symptoms as                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990930 -                    intolerable.  These postoperative findings were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990931 -                    significantly different than preoperative symptoms                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990932 -                    (Fig. 5).  While the majority of patients were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990933 -                    satisfied with their results, 16% were unsatisfied and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
990934 -                    14% were undecided.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990936 -                     ..
990937 -                    FIGURE 5. Pre- and postoperative symptom scores for A, heartburn, B,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
990938 -                    dysphagia, and C, chest pain.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
990939 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990940 -                          http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/figure/f5-3/                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
990942 -                     ..
990943 -                3.  At last follow-up, 17% of patients were using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
990944 -                    antisecretory medications for GI symptoms. Eleven                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990945 -                    percent underwent dilations postoperatively, and at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990946 -                    least 5 patients underwent redo fundoplication or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
990947 -                    takedown of their fundoplications elsewhere.  No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990948 -                    specific data are available for these patients.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990950 -                 ..
990951 -            2.  Multiple Redos                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
990952 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990953 -                1.  Twenty-two patients who underwent a redo                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
990954 -                    fundoplication at Emory went on to have multiple                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990955 -                    redos at Emory (Fig. 2). Five patients underwent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990956 -                    another redo externally.  Since data on these                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
990957 -                    elsewhere redos are not available, they are not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990958 -                    included in this group's analysis. The rate of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990959 -                    second and third redo for patients was 7.1% and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990960 -                    6.8%, respectively (P = NS), more than twice the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990961 -                    rate of revision for our primary fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990962 -                    group (2.8%, P < 0.05).
990964 -                     ..
990965 -                2.  Mean time from first redo to second redo was 24                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990966 -                    33 months, and from second to third redo, 12  7                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990967 -                    months. While 5 of the first redos were done for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990968 -                    acute wrap herniation during the same                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
990969 -                    hospitalization as the initial fundoplication, all                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990970 -                    of the remaining second redos were for chronic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990971 -                    symptomatic failures.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
990973 -                     ..
990974 -                3.  Based upon objective testing, preoperative                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
990975 -                    diagnoses were compared between the first redo and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990976 -                    second redo groups. Findings of transdiaphragmatic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990977 -                    wrap migration and Barrett esophagus were more                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990978 -                    common preoperatively in the second redo group.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990979 -                    There was also a trend away from recurrent GERD as                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990980 -                    a preoperative diagnosis.  Nearly one third of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990981 -                    patients had different preoperative findings at the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990982 -                    time of second redo than at the time of previous                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990983 -                    operation, suggesting a new diagnosis and surgical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990984 -                    indication for the second redo procedure (Fig. 6).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990986 -                     ..
990987 -                    FIGURE 6. Preoperative findings comparing the first                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
990988 -                    failure with the second failed fundoplication.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990989 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
990990 -                          http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/figure/f6-3/                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
990992 -                     ..
990993 -                4.  Operative details, including operative times, type                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990994 -                    of approach, type of fundoplication, operative                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
990995 -                    findings, and complications, were compared between                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990996 -                    the first and second redo groups. There were no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
990997 -                    significant differences between groups in approach                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
990998 -                    or fundoplication type.  A laparoscopic approach                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
990999 -                    predominated (74% in first redo versus 67% in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991000 -                    second redo), with conversion rates of 8% and 6%,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991001 -                    respectively. Conversions were usually due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991002 -                    adhesions or, less commonly, enterotomy.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991003 -                    majority were 360-degree fundoplications in both                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991004 -                    groups, with approximately one fifth of patients                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991005 -                    having partial fundoplications, reflecting the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991006 -                    preoperative incidence of esophageal-body                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
991007 -                    dysfunction. A gastrostomy tube, either operative                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991008 -                    or PEG, was used in 17% of second redos, and a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991009 -                    Heller myotomy was used in 3.7% of second redos.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991011 -                     ..
991012 -                5.  The gold standard for determining the cause of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991013 -                    fundoplication failure is the pattern of failure as                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991014 -                    seen at the time of redo. A second revision in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991015 -                    those patients previously revised at our                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
991016 -                    institution was associated with a significantly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991017 -                    higher rate of fundoplication herniation compared                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991018 -                    with the first redo group (72% versus 50%, P <
991019 -                    0.05).  The finding of a shortened esophagus was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991020 -                    similarly elevated in the second redo (2% versus                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991021 -                    17%, P < 0.05).
991023 -                     ..
991024 -                6.  Those undergoing multiple redos did not experience                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991025 -                    an increased risk of gastric perforation (14% first                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991026 -                    redo versus 17% in second redo, P = NS) or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991027 -                    esophageal perforation (1.4% versus 5.6%, P = NS).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991028 -                    There was no perioperative mortality in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991029 -                    multiple redo group.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
991031 -                     ..
991032 -                7.  Length of stay increased with each revision, from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991033 -                    4.5  3.4 days for the first redo to 5.8  3.0 days                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991034 -                    for second redo and 8.6  3.7 days for those                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991035 -                    undergoing a third redo fundoplication.  There was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991036 -                    no difference in the rates of postoperative                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991037 -                    dysphagia or use of dilation, but those undergoing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991038 -                    a second redo did have a higher rate of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
991039 -                    antisecretory use after their surgery (12% versus                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991040 -                    23%; P < 0.05).
991042 -                     ..
991043 -                8.  Using a univariate logistic regression, we looked                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991044 -                    for risk factors at the time of first redo that may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991045 -                    predict the need for future surgery.  The presence                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991046 -                    of fundoplication herniation at the time of first                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991047 -                    redo was the only significant predictor of the need                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991048 -                    for another redo fundoplication, with an odds ratio                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991049 -                    of 4.   (95% CI 1.212.4).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991051 -         ..
991052 -    7.  DISCUSSION                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991053 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991054 -        1.  Indications for Redo                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991055 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991056 -            1.  Patients who present after a fundoplication with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991057 -                persistent or recurrent foregut symptoms represent a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991058 -                unique challenge.  Increasing numbers of patients are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991059 -                being diagnosed with GERD or paraesophageal hernia, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991060 -                with this, significant numbers of patients who in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991061 -                past would have lived with their foregut symptoms are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991062 -                now receiving interventions.  Since 1991, laparoscopic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991063 -                antireflux surgery, in particular, the most widely                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991064 -                studied and applied operation, the Nissen (360-degree)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991065 -                fundoplication, has seen an 8-fold increase in use.2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991066 -                While largely successful when performed by surgeons                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991067 -                experienced in both laparoscopy and esophageal surgery,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991068 -                even in the most experienced hands, surgery fails to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991069 -                control the patient's symptoms or results in new                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991070 -                symptoms or anatomic problems in 3%-16% of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
991071 -                patients.5,11,16 Some type of revisional surgery may be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991072 -                required in select patients.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
991074 -                 ..
991075 -            2.  In our practice, we consider redo fundoplication for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991076 -                patients with persistent or recurrent foregut symptoms,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991077 -                or in those who develop new foregut symptoms not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991078 -                present before their initial fundoplication.  Redo                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991079 -                surgery is offered to those who then have objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991080 -                evidence of failure based on physiologic studies or an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991081 -                anatomic abnormality. Using this approach, we have had                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991082 -                to redo nearly 3% of our own fundoplications.  We have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991083 -                documented in other publications a higher redo rate in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991084 -                those with more complicated GERD (Barrett, esophagitis,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991085 -                and stricture).15-17 We have also documented a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991086 -                symptomatic failure rate of 7% in those undergoing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991087 -                fundoplication for paraesophageal hernia and an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991088 -                anatomic failure rate of 33% in these same                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
991089 -                patients.13,14 We do not offer a redo for patients with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991090 -                anatomic failure in the absence of foregut symptoms.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991091 -                In particular, we do not feel that a recurrent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991092 -                paraesophageal hernia with its associated mediastinal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991093 -                scarring has the same natural history as a primary                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991094 -                paraesophageal hernia. In our experience, we have never                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991095 -                seen an acute presentation for a recurrent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
991096 -                paraesophageal hernia not occurring in the immediate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991097 -                postoperative period as a result of postoperative                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991098 -                retching!  The most challenging patients have been                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991099 -                those with dysphagia, an anatomically normal-appearing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991100 -                wrap, a normal barium swallow with a 12.5-mm tablet,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991101 -                and normal esophageal pH and motility.  These can be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991102 -                very desperate patients whose desperation has led us to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991103 -                reoperate.  In fact, over half of the redos reported in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991104 -                this paper were on patients with dysphagia. While most                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991105 -                of these patients also had anatomic reasons for their                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991106 -                dysphagia, several presented as described above, and we                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991107 -                have had some dramatically positive outcomes in these                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991108 -                patients, as well as some frustrating negative                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991109 -                outcomes.  The Emory patient who underwent 4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
991110 -                fundoplications was one of these patients. He continues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991111 -                to have dysphagia.  Currently, we would not recommend                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991112 -                reoperation for a patient with dysphagia if an anatomic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991113 -                or physiologic reason for dysphagia cannot be defined                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991114 -                preoperatively.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991116 -                 ..
991117 -            3.  Another challenging patient group has been those with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991118 -                recurrent heartburn or atypical symptoms, only mildly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991119 -                abnormal esophageal pH studies, and no symptom                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991120 -                improvement with antisecretory medication. While redo                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991121 -                fundoplication may be warranted, there is a significant                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991122 -                potential to leave these patients with even worse                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991123 -                foregut symptoms. Before considering a redo in these                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991124 -                patients, we will document failure of acid suppression                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991125 -                with maximum-dose PPIs.  The patient with heartburn                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991126 -                symptoms and appropriate acid suppression on PPIs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991127 -                should not have a redo unless they cannot tolerate PPIs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991128 -                due to severe side effects.  The new endoluminal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991129 -                approaches may offer an attractive alternative to redo                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991130 -                fundoplication for these patients. We have used this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991131 -                approach in several patients, with satisfactory early                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991132 -                results.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
991134 -             ..
991135 -        2.  Choice of Approach                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991136 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991137 -            In our paper published in 1999, we detailed comparable                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991138 -            outcomes whether the redo operation was performed using an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991139 -            open or laparoscopic approach.  Our more recent experience                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991140 -            continues to support the utility of a laparoscopic approach                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991141 -            for redos, even when the initial fundoplications was open.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991142 -            The conversion rate in those in whom a prior open                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
991143 -            fundoplication was approached laparoscopically was 22%, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991144 -            overall 77% of redos in this series were completed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991145 -            laparoscopically.  At times a primary open redo is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991146 -            selected, especially for patients whose prior foregut                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991147 -            surgery was complicated (eg, GI perforation with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
991148 -            perioperative abdominal sepsis or prior transthoracic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991149 -            approach with chest complications).  There was no increase                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991150 -            in intraoperative complications or postoperative                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
991151 -            complications in the laparoscopic group.  In fact, gastric                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991152 -            and esophageal perforation was more common in those                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991153 -            undergoing either primary open redo or converted to open                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991154 -            redo.  This most likely reflects the complexity of the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991155 -            cases that need to be performed with an open approach.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991156 -            However, the laparoscopic group realized a lower incidence                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991157 -            of the postoperative complications of pneumonia, wound                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991158 -            infection, atelectasis and ileus.  As our experience with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991159 -            these operations has increased, we are infrequently using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991160 -            an open approach, and over the past 23 months we have used                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991161 -            a primary open approach in only 4 of 48 patients (8%).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991163 -             ..
991164 -        3.  Technical Challenges                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991165 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991166 -            1.  Reoperative esophageal surgery can be one of the most                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991167 -                challenging procedures that a GI surgeon will face.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991168 -                Anatomy can be severely distorted by scarring,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991169 -                fundoplication herniation, and unexpected findings.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991170 -                Experience and knowledge of normal and abnormal anatomy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991171 -                is critical to not only a safe operation but also                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991172 -                effective resolution of the patient's problems.  This                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991173 -                experience documents a low rate of significant                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991174 -                complications and death despite the challenges of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991175 -                reoperative foregut surgery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
991177 -                 ..
991178 -            2.  The preoperative reason for failure is not always what                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991179 -                is found during surgery.  In the external primary                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991180 -                fundoplication group undergoing redo fundoplication,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991181 -                the preredo diagnosis was GERD in the majority of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991182 -                patients.  This would suggest that a loose wrap would                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991183 -                be found during surgery.  In fact, several patients                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991184 -                were found to have twisted wraps without an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
991185 -                appropriately mobilized gastric fundus (short gastric                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991186 -                vessels intact) or misplaced or loose wraps (Fig. 5A,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991187 -                B). Very few had simply a disrupted fundoplication.  In                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991188 -                all cases, we take down the prior fundoplication and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991189 -                redo the entire operation.  In one patient with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991190 -                dysphagia and a very normal-appearing wrap, after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991191 -                complete mobilization of the fundoplication, a Penrose                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991192 -                drain was found wrapped around the distal esophagus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991193 -                In several other patients, unexpected foreign material                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991194 -                was found, including hernia tacks used for the crural                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991195 -                approximation and fundoplication and mesh when the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991196 -                first operation mentioned nothing about hiatal hernia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991197 -                or the use of mesh.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991199 -             ..
991200 -        4.  Diminishing Success With Each Redo                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991201 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991202 -            Perhaps most significant is the data revealing a higher                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991203 -            rate of failure with a redo when compared with a first-time                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991204 -            fundoplication.  While it is intuitive that the best                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991205 -            outcome will be with the first fundoplication, it is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991206 -            perhaps surprising that the failure rate with 1 redo is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991207 -            only 7.1% and not higher.  This is, however, nearly 3 times                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991208 -            the redo rate after a first-time fundoplication.  With a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991209 -            third redo, the failure rate does not appear to increase,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991210 -            but after 3 redos, it looks like the chance of subsequent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991211 -            failure becomes prohibitive.  While not detailed here, we                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991212 -            now seriously consider esophagectomy after 4 failures                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991213 -            (primary and 3 redos). Over the past 4 years, this has been                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991214 -            necessary in fewer than 10 patients.  The only exception to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991215 -            this is the patient who has a redo during which very                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991216 -            little is done (ie, more of an exploratory procedure than a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991217 -            true attempted redo). Many patients have undergone a redo,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991218 -            but at the time of another redo, virginal tissue plans are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991219 -            encountered, suggesting a limited dissection in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991220 -            previous procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991222 -             ..
991223 -        5.  Mechanism of Failure: Future                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
991224 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991225 -            1.  Fundoplication herniation was the most common mechanism                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991226 -                of failure in our 1999 series of 100 redos, and it                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991227 -                remains the most common mechanism of failure, even in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991228 -                our own patients requiring redo fundoplication.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991229 -                Clearly there is a need to better understand the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991230 -                mechanics the esophageal hiatus and its reconstruction.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991231 -                The etiology of this mechanism of failure is unclear.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991232 -                Some have suggested that esophageal shortening                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991233 -                predisposes to fundoplication herniation and that an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991234 -                esophageal lengthening should accompany all hiatal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991235 -                hernia repairs.  We have looked carefully at our own                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991236 -                experience with both the short esophagus and esophageal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991237 -                lengthening and have found true esophageal shortening                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991238 -                to be unusual (<2% when assessed intraoperatively).
991239 -                Esophageal lengthening, while providing an esthetically                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991240 -                pleasing intraoperative result, has resulted in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991241 -                uncontrolled esophagitis or pathologic esophageal acid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991242 -                exposure in 80% of patients postoperatively.18 Except                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991243 -                in the extreme situation, esophageal lengthening should                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991244 -                rarely be indicated. Another often-discussed issue is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991245 -                the idea that hiatal hernias should be subjected to a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991246 -                tension-free repair, as is now widely accepted for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991247 -                abdominal wall hernias. Many are advocating routine use                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991248 -                of mesh for reconstruction of the esophageal hiatus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991249 -                Several prospective studies have documented improved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991250 -                outcomes with mesh hiatoplasty; however, numbers are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991251 -                small and follow-up is short.9 We have avoided mesh                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991252 -                except for the largest of hiatal defects due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991253 -                concerns about placing an inflammatory foreign body                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991254 -                next to the esophagus and our anecdotal experience in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991255 -                several patients where mesh eroded into the esophagus                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991256 -                or caused significant esophageal stenosis.  Clearly,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991257 -                work needs to focus on improving our management of the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991258 -                esophageal hiatus during fundoplication to improve the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991259 -                results of this operation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
991261 -                 ..
991262 -            2.  Finally, a comment about follow-up. As detailed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991263 -                earlier, we have made a commitment to maintaining                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991264 -                contact with our patients through our full-time                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991265 -                research nurse and follow-up strategy. Even with such                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991266 -                efforts, follow-up is incomplete and extremely                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991267 -                difficult to maintain.  After 1 year, just over half of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991268 -                our patients respond to requests for follow-up.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991269 -                optimist and fundoplication enthusiast offers the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991270 -                theory that in such a mobile society, most patients are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991271 -                doing so well after this operation that they cannot be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991272 -                bothered with follow-up. On the other hand, many                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991273 -                surgery enthusiasts have announced this theory only to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991274 -                be dashed by a colleague in the room claiming to be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991275 -                caring for increasing numbers of patients with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991276 -                failures.  As a quaternary referral center for foregut                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991277 -                conditions, we join the optimist group, hoping that if                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991278 -                significant numbers of our patients were requiring redo                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991279 -                surgery, the patients would be coming back to us or we                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991280 -                would hear about this from our colleagues.  That being                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991281 -                said, the lack of objective long-term follow-up,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991282 -                combined with an unclear definition of failure (back on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991283 -                medication versus need for more surgery), continues to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991284 -                fuel the debate over the role of fundoplication in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991285 -                management of the GERD patient, and this series does                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991286 -                not resolve the debate.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991288 -                 ..
991289 -            3.  In summary, carefully selected patients who have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991290 -                recurrent or persistent problems after fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991291 -                can safely undergo redo fundoplication with good                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991292 -                results. In experienced hands, most patients can be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991293 -                approached laparoscopically.  Ideally, documented                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991294 -                long-term follow-up will allow continued evolution of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991295 -                the care for the foregut patient, thereby providing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991296 -                ever improving outcomes, but follow-up remains                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991297 -                problematic.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
991299 -             ..
991300 -        6.  Discussions                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991301 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991302 -            4.  Dr William O Richards (Nashville, Tennessee):  Drs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991303 -                Smith, Hunter, and colleagues are to be congratulated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991304 -                on the significant work they have accomplished with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991305 -                this report with redo Nissen fundoplications.  I want                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991306 -                to emphasize several important aspects about their                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991307 -                experience.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
991309 -                 ..
991310 -            5.  Their results after redo operations are really                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991311 -                outstanding.  They were able to perform the majority of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991312 -                these redo operations laparoscopically with excellent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991313 -                results and very low morbidity. In the manuscript, the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991314 -                authors report five patients from their own experience                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991315 -                who presented with acute herniation of the intact wrap                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991316 -                in the early postoperative period that was related to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991317 -                nausea and retching.  Could the authors expand on these                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991318 -                cases and tell us if they were in any way related to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991319 -                inadequate crural closure and if they recommend any                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991320 -                changes in the crural closure or postoperative care                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991321 -                that can decrease the risk of herniation?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
991323 -                 ..
991324 -            6.  Second, about half of their redo cases were related to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991325 -                dysphagia in an angulated route, but 3.7% of the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991326 -                patients undergoing a second redo operation underwent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991327 -                Heller myotomy in the manuscript. Secondary achalasia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991328 -                caused by the wrap occurs in a small number of patients                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991329 -                undergoing fundoplication at Vanderbilt.  We believe                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991330 -                that takedown of the Nissen and performance of a Heller                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991331 -                myotomy is the best operation for these patients with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991332 -                secondary achalasia.  I would like to hear how you                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991333 -                handle the patients who have manometric findings of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991334 -                achalasia after Nissen fundoplication.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991336 -                 ..
991337 -            7.  Finally, about half the redo operations were performed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991338 -                to alleviate recurrent GERD, but redo Nissen, even with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991339 -                your excellent results, was associated with a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
991340 -                significant conversion rate, increased hospitalization,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991341 -                and increased risk of another reoperation compared to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991342 -                your primary operations.  The new endoluminal therapies                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991343 -                may be able to improve the antireflux barrier                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
991344 -                significantly and avoid performing a redo Nissen                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991345 -                fundoplication.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991347 -                 ..
991348 -            8.  In patients with a partially disrupted wrap and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991349 -                recurrent GERD but with no significant dysphagia, I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991350 -                would preferentially perform a Stretta procedure or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991351 -                another completely endoluminal therapy rather than                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991352 -                attempting a redo Nissen.  I would be interested in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991353 -                your thoughts as to which patients are best suited for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991354 -                this approach.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991356 -                 ..
991357 -            9.  Dr Blair A Jobe (Portland, Oregon): I wish to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
991358 -                congratulate Dr.  Smith and his colleagues on this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991359 -                excellent study and for assembling what is now the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991360 -                largest series of reoperations for failed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
991361 -                fundoplication.  The opportunity to gain insight into                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991362 -                the mechanisms by which our procedures fall down is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991363 -                both valuable and rare.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991365 -                 ..
991366 -           10.  The tremendous success of Nissen fundoplication has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991367 -                been founded in the tenets of proper patient selection                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991368 -                and an adherence to the technical fundamentals of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991369 -                reconstruction, that is, division of the short gastric                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991370 -                vessels, return of the esophagogastric junction into                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991371 -                the abdominal cavity, crural closure, and the creation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991372 -                of a short floppy fundoplication around the distal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991373 -                esophagus.  Despite these advances in technique, a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991374 -                small percentage of these patients will develop                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991375 -                recurrent symptoms and the need for revision as the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991376 -                result of incompetence of the cardia, esophageal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991377 -                obstruction, or both.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991379 -                 ..
991380 -           11.  This study brings several important points to light.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991381 -                First, similar to the findings of others, the most                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991382 -                common cause of failure resulting in reoperation was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991383 -                herniation of the esophagogastric junction (with or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991384 -                without the fundoplication) into the chest.  Second,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991385 -                the presence of fundoplication herniation at the time                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991386 -                of the first reoperation was a significant risk factor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991387 -                for a subsequent failure, which would require another                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991388 -                operative repair.  Third, the laparoscopic approach to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991389 -                fundoplication failure results in good short-term                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991390 -                clinical outcomes and low morbidity in experienced                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991391 -                hands.  Finally, failures, which are rare, occur within                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991392 -                2 years of the primary operation.  Based on these                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991393 -                findings, I have several questions.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991395 -                 ..
991396 -           12.  Perhaps we have been too simplistic in how we                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
991397 -                conceptualize herniation after fundoplication.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991398 -                age-old debate is whether herniation occurs as a result                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991399 -                of an unrecognized short esophagus, crural dehiscence,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991400 -                or elements of both.  Is it unrealistic to think that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991401 -                we can place these dynamic and continually moving                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991402 -                structures adjacent to each other and not have some                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991403 -                element of herniation?  The esophagus shortens with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991404 -                each swallow and the diaphragm flattens with each                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991405 -                breath. This is bound to place stress on the crural                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991406 -                closure and fundoplication.  With this in mind, should                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991407 -                Collis gastroplasty be used more liberally in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991408 -                primary operation, or is the risk for continued                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991409 -                esophageal injury too great?  Did the majority of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991410 -                patients that herniated have complicated reflux                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991411 -                (Barrett metaplasia, stricture) or a diaphragmatic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991412 -                stressor?  In light of your results, will you modify                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991413 -                your approach when herniation after a primary repair is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991414 -                encountered?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
991416 -                 ..
991417 -           13.  From your data, it appears as if the incidence of the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991418 -                malformed wrap is decreasing.  In your study of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991419 -                fundoplication failure in 1999, the most common cause                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991420 -                of failure in patients who were referred to Emory was a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991421 -                twisted or slipped wrap.  In the current study, the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991422 -                referral consists primarily of patients with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
991423 -                herniation. Why do you think this pattern has shifted?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991425 -                 ..
991426 -           14.  Finally, as Dr Richards brought up, is there a role for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991427 -                endoscopic antireflux techniques in the tune-up of an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991428 -                anatomically intact fundoplication which allows reflux?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991430 -                 ..
991431 -           15.  Dr J David Richardson (Louisville, Kentucky): What do                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991432 -                you do with the occasional patient at the far end of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991433 -                the spectrum who has had sort of a disastrous failure?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991434 -                I have operated on several of these patients recently                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991435 -                where the entire fundoplication is in the chest and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991436 -                nothing is working.  Often, the wrap cannot be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991437 -                anatomically returned to the abdomen with a laparoscope                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991438 -                or run open.  What do you do with those patients who                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991439 -                are quite challenging?  The authors stressed that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991440 -                experienced hands are important in managing these                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991441 -                patients, but there is a lot of esophageal surgery                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991442 -                being done by relatively inexperienced surgeons.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991444 -                 ..
991445 -           16.  Dr Robert V Rege (Dallas, Texas): I would like to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991446 -                congratulate you on your paper.  When you are done with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991447 -                all of the redos and multiple redos, there is a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991448 -                significant number of patients left over which are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991449 -                troublesome for us because they show up at referral                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991450 -                centers.  And those are the patients that do not have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991451 -                physiologic or anatomic reasons to redo the wrap again                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991452 -                but continue to be dissatisfied with the results.  I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991453 -                would like to know how you handle these.  Do you ever                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991454 -                take the wrap apart and give up on the reflux procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991455 -                in those patients?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991457 -                 ..
991458 -           17.  Dr C Daniel Smith (Atlanta, Georgia): Thank you for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991459 -                these wonderful questions.  As you might suspect, with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991460 -                this experience we have struggled with a lot of these                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991461 -                same issues for years and years in managing these                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991462 -                patients.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
991464 -                 ..
991465 -           18.  Dr Richards asked questions about the 5 patients who                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991466 -                had acute wrap herniation and what we have done, if                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991467 -                anything, to try to manage that, and in particular, do                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991468 -                we do anything different with the crura?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
991470 -                 ..
991471 -           19.  In each of these cases, the patients experienced acute                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991472 -                postoperative retching.  The first thing we have done                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991473 -                is implemented a policy of antinausea control and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991474 -                antiemetics.  We are very aggressive about all patients                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991475 -                getting preemptive nausea control.  With that, in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991476 -                last 2 years we have not had any patients who have had                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991477 -                acute herniation and needed to go back to the operating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991478 -                room.  So I think retching prevention and nausea                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991479 -                prevention is number 1.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991481 -                 ..
991482 -           20.  When you go back in on those few who have acute                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991483 -                herniation, it is hard to know what may have been                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991484 -                etiologic, if anything, at the time of the first                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991485 -                operation.  Usually, there is a stitch that has popped                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991486 -                loose in the crura as the wrap has herniated.  We have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991487 -                not been able to determine any issues related to the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991488 -                crura and how we handled the crura in those patients.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991490 -                 ..
991491 -           21.  The second question had to do with myotomy and the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991492 -                proposal of more liberal use of myotomy.  We will do a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991493 -                myotomy, but only if we can't find an anatomic basis at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991494 -                the time of the second operation for esophageal outlet                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991495 -                obstruction, and the patient has aperistalsis on their                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991496 -                preoperative motility.  In contrast, if we have any                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991497 -                element of preserved motility or body function and we                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991498 -                find a bit of a twist or tightness of the wrap, we will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991499 -                not do a myotomy.  That is why our myotomy rate is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991500 -                fairly low. Again, we will apply it for the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
991501 -                aperistaltic esophagus when everything else looks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991502 -                fairly normal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991504 -                 ..
991505 -           22.  Regarding the use of Stretta or endoluminal therapy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991506 -                endoluminal therapy; absolutely, to both Drs.  Jobe and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991507 -                Richards.  I think this is an application of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
991508 -                endoluminal therapy that I am probably most eager to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991509 -                see developed, and we are doing it.  Our preliminary                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991510 -                results are fairly favorable.  Even if you can only                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991511 -                achieve acid control in 50% of patients with an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991512 -                endoluminal therapy, that is half of the patients who                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991513 -                may not go on to the risks of a redo operation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991514 -                However, I think the endoluminal therapies are really                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991515 -                only appropriate for the patients who have recurrent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991516 -                GERD and clear anatomic evidence of a disrupted wrap.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991517 -                It is a fairly small number of patients, but I think                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991518 -                for those patients this is very appropriate.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
991520 -                 ..
991521 -           23.  Regarding Dr Jobe's question about complicated GERD, I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991522 -                think the answer is yes, no question, the patients who                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991523 -                have Barrett esophagitis or stricture have an 8%                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991524 -                failure rate. But we have patients in this group who                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991525 -                also had herniation because of things like abdominal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991526 -                trauma or episodes of reaching years after surgery and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991527 -                even some patients where we have no explanation for why                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991528 -                they have this problem.  So you certainly should                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991529 -                suspect it in the patients with complex reflux.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991531 -                 ..
991532 -           24.  Regarding liberal use of the Collis gastroplasty, we                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991533 -                looked at our own experience.  We found that 80% of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991534 -                patients who have undergone a Collis gastroplasty have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991535 -                persistent esophageal acid exposure after that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991536 -                operation.  I believe it is a good operation.  But it                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991537 -                has to be done correctly.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
991539 -                 ..
991540 -           25.  You cannot get unlimited length with a Collis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
991541 -                gastroplasty.  You can probably only get 2 cm of length                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991542 -                by creating the wrap around the neoesophagus.  If you                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991543 -                do that, you will probably avoid the persistent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991544 -                esophageal acid exposure.  I really don't think we                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991545 -                should be looking at more liberal use of the Collis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991546 -                because there is a considerable risk of continued acid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991547 -                exposure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
991549 -                 ..
991550 -           26.  Why are we seeing fewer misplaced wraps or malformed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991551 -                wraps?  I think there are probably 2 answers to that.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991552 -                Number 1, people are learning how to do this operation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991553 -                They are being more aggressive about taking down the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991554 -                short gastric vessels and those other principles that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991555 -                we all come to understand.  Number 2, I think fewer                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991556 -                surgeons are doing this operation. More of these                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991557 -                operations are now coming to referral centers and are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991558 -                consolidating in centers of excellence, in part because                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991559 -                of the reports 3 and 4 years ago calling into question                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991560 -                the success of this operation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
991562 -                 ..
991563 -           27.  Dr Richardson asked about the disaster patient. We do a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991564 -                combined abdominal chest approach.  We will leave the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991565 -                patient without a wrap if we have to.  We have not left                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991566 -                any wraps in the chest. We have had concerns about                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991567 -                reported incidents of perforation in those situations.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991568 -                We have done some esophagectomies.  If you have the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991569 -                end-stage patient, you just take their esophagus out.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991571 -                 ..
991572 -           28.  Dr Rege asked about the patient in whom you really                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991573 -                cannot find any anatomic basis for failure, what do we                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991574 -                do, counseling, sit on our hands?  Every time we do a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991575 -                redo, we take a wrap entirely apart. We have a few                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991576 -                patients that we have not rewrapped.  I will tell you                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991577 -                hands down, for the patient who does not have an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991578 -                objective basis for reoperation, you should not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991579 -                reoperate.  Those patients will inevitably do very                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991580 -                poorly.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991582 -             ..
991583 -        7.  Footnotes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991585 -             ..
991586 -            Reprints: C. Daniel Smith, MD, Department of Surgery, Emory                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991587 -            University School of Medicine, 1364 Clifton Road, NE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991588 -            (H124), Atlanta, GA 30322.  E-mail: ude.yrome@72timsc.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991590 -             ..
991591 -        8.  REFERENCES                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991592 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991593 -            1.  Dallemagne B, Weerts JM, Jehaes C, et al.  Laparoscopic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991594 -                Nissen fundoplication: preliminary report.  Surg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991595 -                Laparosc Endosc. 1991;1:138143. [PubMed]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
991596 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991597 -            2.  Morton J, Lucktong T, Behrns KE, et al. National trends                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991598 -                in fundoplication utilization and outcomes from 1989                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991599 -                and 1999. J Am Coll Surg. 2002;195:S55. 3.  Anvari M,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991600 -                Allen C. Five-year comprehensive outcomes evaluation in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991601 -                181 patients after laparoscopic Nissen fundoplication.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991602 -                J Am Coll Surg. 2003;196:5159. [PubMed]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
991604 -                 ..
991605 -            3.  Bammer T, Hinder RA, Klaus A, et al. Five- to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
991606 -                eight-year outcome of the first laparoscopic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
991607 -                fundoplications. J Gastrointest Surg. 2001;5:4248.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991608 -                [PubMed]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
991610 -                 ..
991611 -            4.  Catarci M, Gentileschi P, Papi C, et al.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
991612 -                Evidence-based appraisal of antireflux fundoplication.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991613 -                Ann Surg. 2004;239:325337. [PMC free article] [PubMed]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991615 -                 ..
991616 -            5.  Dassinger MS, Torquati A, Houston HL, et al.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
991617 -                Laparoscopic fundoplication: 5-year follow-up.  Am                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991618 -                Surg. 2004;70:691694. [PubMed]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991620 -                 ..
991621 -            6.  Lafullarde T, Watson DI, Jamieson GG, et al.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
991622 -                Laparoscopic Nissen fundoplication: five-year results                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991623 -                and beyond.  Arch Surg. 2001;136:180184. [PubMed]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
991625 -                 ..
991626 -            7.  Peters JH, DeMeester TR, Crookes PF, et al.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991627 -                treatment of gastroesophageal reflux disease with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991628 -                laparoscopic Nissen fundoplication: prospective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991629 -                evaluation of 100 patients with typical symptoms.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991630 -                Ann Surg. 1998;228:4050. [PMC free article] [PubMed]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991632 -                 ..
991633 -            8.  Arguedas MR, Heudebert GR, Klapow JC, et al.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
991634 -                Re-examination of the cost-effectiveness of surgical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991635 -                versus medical therapy in patients with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991636 -                gastroesophageal reflux disease: the value of long-term                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991637 -                data collection.  Am J Gastroenterol.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991638 -                2004;99:10231028. [PubMed]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
991640 -                 ..
991641 -            9.  Spechler SJ.  Medical or invasive therapy for GERD: an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991642 -                acidulous analysis.  Clin Gastroenterol Hepatol.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991643 -                2003;1:8188. [PubMed]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991645 -                 ..
991646 -           10.  Spechler SJ, Lee E, Ahnen D, et al.  Long-term outcome                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991647 -                of medical and surgical therapies for gastroesophageal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991648 -                reflux disease.  JAMA. 2001;285:23312338. [PubMed]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991650 -                 ..
991651 -           11.  Hashemi M, Peters JH, DeMeester TR, et al.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
991652 -                Laparoscopic repair of large type III hiatal hernia:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991653 -                objective followup reveals high recurrence rate. J Am                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991654 -                Coll Surg. 2000;190:553560. [PubMed]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
991656 -                 ..
991657 -           12.  Mattar SG, Bowers SP, Bradshaw WA, et al.  Laparoscopic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991658 -                repair of paraesophageal hernia is subject to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
991659 -                recurrence but rarely requires reoperation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
991660 -                Gastroenterology. 2001;120:A479.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991662 -                 ..
991663 -           13.  Mattar SG, Bowers SP, Galloway KD, et al.  Long-term                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991664 -                outcome of laparoscopic repair of paraesophageal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991665 -                hernia.  Surg Endosc. 2002;16:745749. [PubMed]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991667 -                 ..
991668 -           14.  Hunter JG, Smith CD, Branum GD, et al.  Laparoscopic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991669 -                fundoplication failures: patterns of failure and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991670 -                response to fundoplication revision.  Ann Surg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
991671 -                1999;230:595604. [PMC free article] [PubMed]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
991673 -                 ..
991674 -           15.  Terry M, Smith CD, Branum GD, et al.  Outcomes of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991675 -                laparoscopic fundoplication for gastroesophageal reflux                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
991676 -                disease and paraesophageal hernia.  Surg Endosc.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991677 -                2001;15:691699. [PubMed]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
991679 -                 ..
991680 -           16.  Bowers SP, Mattar SG, Smith CD, et al.  Clinical and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
991681 -                histologic follow-up after antireflux surgery for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
991682 -                Barrett's esophagus. J Gastrointest Surg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
991683 -                2002;6:532538. [PubMed]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
991685 -                 ..
991686 -           17.  Lin E, Swafford V, Chadalavada R, et al.  Disparity                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
991687 -                between symptomatic and physiologic outcomes following                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
991688 -                esophageal lengthening procedures for antireflux                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
991689 -                surgery. J Gastrointest Surg. 2004;8:3139. [PubMed]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
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