April 1995 SSAT A1237

• A NEW TOOL TO MEASURE OUTCOME OF THERAPY SHOWS IMPROVED QUALrrY OF LIFE Ab-TER LAPAROSCOPIC NISSEN FUNDOPLICATION. M. O'Toole. C. Pooe. R.A. Devo. C.A. Pellegrini. Departments of Medicine and Surgery, University of Washington.

Traditionally, the outcome of therapy for gastroesophageal reflux (GER) has been assessed objectively, using manometry, 24-h pH studies and endoscopy, or subjectively, measuring the response of selected GER symptoms to therapy. While these measures indicate the effects of treatment on the disease process, they do not always reflect accurately how the patient feels, i.e., quality of life (QOL). We developed a thorough, easy to use questionnaire to explore GER and other foregut symptoms (17 items), mood status (8 items) and functional status (7 items) and tested our new tool on 40 consecutive patients operated on for abnormal GER by one surgeon over a 9 month period. All patients were tested before and 3 months after laparoscopic Nissen fundoplication. Each patient served as its own control. Each question was entered in Systat FPU5.2.1. as a variable with a value of 6 to 4. Groups of related questions were summed as scale scores. T-tests were performed on individual variables and Spearmann correlations were done to measure internal consistency of questions and scales. Maximum possible score (best scenario) was 132. The results were as follows:

SCALE Pre-opt Post-Opt Change* Symptoms 20.35 (7-33) 46.90 (17-64) 26.6(5-52) Mood 14.20 (1-31) 21.60 (5-33) 7.4(16-28) Function 10.30 (1-19) t3.25 (2-20) 3.0(-6-12) OOL 54.50 (10-90) 91.7S(29-128~ 37.3(6-95~ t~ range. * p < 0.05

The highest correlation was between mood and function scales (r=0.88), followed by symptoms vs. mood (r=0.80). Thus, with this new tool it is possible to measure the effects of GER symptoms on the patient's QOL (which may help define indications for medical or surgical therapy,) and the effects of a given treatment on QOL (which may help compare treatment modalities). Furthermore, our study shows that in patients with GER, symptoms, mood and function are intertwined and respond similarly to treatment and that laparoscopic Nissen fundoplication dramatically improves the patients' overall QOL.

THE ROLE OF STRICTUREPLASTY IN THE MANAGEMENT OF CROHN'S DISEASE: HOW SAFE IS IT? G. Ozuner, MD and V.W. Fazio, MD, Department of Colorectal Surgery, Cleveland Clinic Foundation. Cleveland, Ohio.

Strictureplasty (SXPL) is a well accepted technique in the management of selected patients with Crohn's disease. To determine the safety, applicability, perioperative complications, effectiveness and long-term results of SXPL in Crohn's disease; the experience at a single institution was reviewed. A retrospective analysis of all patients undergoing SXPL between 6/84 and 7/94 was performed. Duration of Crohn's disease, associated medical and surgical history, indications for SXPL, medications and lab data, intraoperative findings, complications and long term outcome was analyzed. One hundred fifty two patients (82 M, 70 F) underwent 178 operations for a total of 654 strictureplasties (Heineke- Mikulicz 589; Finney 65). Median number of SXPL was three and the median age of the patients was 36 years. No mortality occurred. Median hospital stay was eight days. Perioperative septic complications (intra-abdominal abscess, fistula, leak) were noted in eight patients (5%), and reoperation for sepsis was needed in three patients. Post strietureplasty hemorrhage requiring transfusion was noted in 20 patients (13%) of which two required nonoperative intervention. Relief of obstructive symptoms was achieved in 98% of the patients. Rate of restric- ture or new stricture/perforative disease was observed in 4% and 18% respectively during a 39 month median follow-up. SXPL is a safe and effec- tive procedure for small bowel Crohn's disease in certain patients; particularly those with mul- tiple obstructions and those vulnerable to short bowel syndrome. Perioperative complications are few and long-term results are gratifying.

LAPAROSCOPIC INCISIONAL HERNIA REPAIR - ONGOING EXPERIENCE. A Park*, M Gaqner+, A Pomp+, *Department of Surgery, St. Joseph's Hospital, McMaster University, Hamilton, Ontario. +Department of Surgery, Hotel Dieu de Montreal, Montreal, Quebec.

Laparoscopic incisional hernia repair has been developed to try to address the issues of painful post op recovery and delayed return to normal activities associated with conventional mesh repair. We have described a technique of laparoscopic incisional hernia repair and now review our experience with 25 cases. Using a 3 or 4 trochar (2,10 mm & 1 or 2 5 nun) approach and a 3~ laparoscope, adhesions were lysed and mesh positioned to overlap fascial margins by at least 2 cms. The hernia sac was not excised. The method of securing the mesh is described. 25 hernias in 23 patients ~9 women, 14 men) ranging in size from l0 cm to 420 cm ~ (mean 104 cm L ) were repaired using PTFE patch (12) and Prolene mesh (13). OR time ranged from 1 to 3 hrs (mean 1.8 hrs). Post op stay ranged from 1 to 17 days (median 3 days, mean 4.3 days). Follow up now extends to 20 months with a range of 1 to 20 months (mean 9 months). Post op complications include ileus (3), trochar site infection (i) and urinary retention (2). Most patients develop a transient resolving seroma, none infected nor requiring drainage. There has been 1 hernia recurrence to date (67 yo man, 2 months post op). Although prospective comparison with conventional repair and longer follow up are needed, our experience with the laparoscopic repair of incisional hernias reveals it to be technically feasible allowing patients prompt resumption of regular activities. This is accomplished with minimal morbidity and a recurrence rate of 4% to date.

Q LAPAROSCOPIC SPLENECTOMY BY LATERAL APPROACH - ONGOING EXPERIENCE. A Park*, M Gaqner+,_AA Pomp+, *Department of Surgery, St. Joseph~s Hospital, McMaster University, Hamilton, Ontario. +Department of Surgery, Hotel Dieu de Montreal, Montreal, Quebec.

Laparoscopic splenectomy compared with conv- entional splenectomy has been shown to reduce post operative hospital stay and result in more rapid return to work. Having tried the anter- ior, 5 trochar approach we developed a 4 troch- ar lateral approach and now present our exper- ience with 18 cases. All patients were placed in the right lateral decubitus position. An Ii mm trochar is inserted in the left subcostal region, two I0 mm trochars in the flank and a 5 mm trochar dorsally. A 30 ~ laparoscope is used. The technique is described. Splenectomy was performed for I.T.P.(6), T.T.P.(2), Evan's Syndrome(l), Hairy Cell Leukemia (i), Hereditary Spherocytosis(1), Hemolytic Anemia (2), Lymphoma(4), Hypersplenism ~ to Portal Hypertension(l, only case where splenic artery embolized pre-op). Overall OR times ranged from 75 to 310 mins with a median of 160 mins and a mean of 161.4 mins. Spleen size varied from 7 to 27 cms weighing 70 to 4313 grams (mean 676.5 grams). Post op stays ranged from 2 to 22 days. (Median 3 days, mean 6.3 days). 1 patient was converted (Portal Hypertension). No post op abscesses, bleeding nor pancreatic injury occured in these laparoscopic cases. The lateral approach affords superior visual- ization of and access to splenic hilar struc- tures. Superb anatomic exposure allows easier dissection, even with large spleens the tail of pancreas can be seen and avoided. Over a wide range of pathology, spleen size and patient habitus this approach has been demonstrated to be feasible and reliable, the approach of choice for laparoscopic splenectomy.