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2005-12-31T05:01:00.000-05:00

Gastroesophageal reflux disease is a chronic disorder that requires long-term therapy in most patients. The appropriate medical therapy should be individualized to the severity of symptoms, the degree of esophagitist and the presence of other acid-reflux complications. Lifestyle changes should form the basis of any therapeutic approach. In patients with mild to moderate disease, initial therapy with histamine [H.sub.2]-receptor antagonists in conventional dosages is suggested. Prokinetic agents are potentially useful in patients with impaired esophageal or gastric motor function, but their efficacy as single agents does not appear to surpass that of standard doses of [H.sub.2] blockers. Sucralfate, a cytoprotective agent, is an additional therapeutic option. For patients with more severe disease, omeprazole and lansoprazole provide unequaled healing rates and accelerated symptom relief. In most patients, maintenance therapy is vital. Surgery is indicated in patients whose disease is refractory to medical therapy and in those who develop complications not amenable to medical therapy.

The phrase "gastroesophageal reflux disease" denotes abnormal acid exposure of the esophagus, which leads to reflux esophagitis.[1] The degree of damage to the esophageal mucosa correlates with the extent of acid and pepsin exposure, as measured by prolonged intraesophageal monitoring with a pH probe. Increased acid clearance time, decreased mucosal resistance and delayed gastric emptying, as well as hiatal hernia and reflux of alkaline fluid, appear to be involved in the pathogenesis of esophagitis. However, the most common mechanism thought to underlie reflux episodes is transient lower esophageal sphincter (LES) relaxation, an abrupt reduction in LES pressure that is not precipitated by swallowing.[2]

Both traditional and newer therapies have, for the most part, focused on reducing esophageal acid exposure by inhibiting or neutralizing acid secretion and improving LES pressure and esophageal clearance.[3-7] The healing rate, successful achievement of complete healing and maintenance of remission are clearly correlated with limited acid exposure.[8]

Phase 1 Medical Therapy

Traditional "phase 1" medical therapy for reflux esophagitis includes postural methods (remaining upright following meals and at bedtime), avoidance of tight-fitting garments, weight loss if appropriate, modifications in dietary habits (avoiding large meals and foods that lower LES pressure, such as fats, chocolate and coffee), cessation of smoking and alcohol use, and avoidance of drugs that reduce LES tone, such as theophylline, calcium channel blockers and anticholinergic agents.[9] A recent report suggested relaxation training as an adjunct to antireflux therapy in patients who experience increased symptoms during times of stress.[10] Table 1 summarizes the nonpharmacologic treatment of gastroesophageal reflux disease.

TABLE 1 
 
Nonpharmacologic Treatment(*) 
of Gastroesophageal Reflux Disease 
 
Elevate head of bed. 
Avoid tight-fitting garments. 
Weight loss, if overweight. 
Dietary modifications--avoid large meals, fatty 
foods, chocolate, peppermint, coffee, carbonated 
beverages and citrus juices. 
Remain upright for three to four hours after meals. 
Stop smoking and avoid alcohol. 
Avoid drugs that reduce LES tone: 
alpha-adrenergic antagonists, anticholinergics, 
beta-adrenergic agonists, calcium channel 
blockers, nitrates, theophylline. 
 
LES = rawer esophageal sphincter. 
(*)--Phase 1 treatment.

Although antacids are the most commonly used agents in the treatment of reflux symptoms, evidence of significant symptomatic or endoscopic improvement with these agents is lacking. Gaviscon, an alginic acid-antacid combination, has been reported to provide better symptom relief than antacids alone.[11]

Although antacids are appropriate for occasional symptomatic relief, they are inadequate therapy for frequent esophagitis symptoms. Antacids have a short duration of action (secondary to rapid clearance from the esophagus and transient neutralization of gastric acid) and no effect on nocturnal acid secretion. Over-the counter histamine [H.sub.2]-receptor antagonists (Table 2) are a recent addition to phase 1 medical therapy. The impact of these drugs on patients' medical care-seeking behavior is unknown.

[TABULAR DATA 2 OMITTED]

Phase 2 Medical Therapy

In this article, it is assumed that the diagnosis of gastroesophageal reflux disease has been secured through esophagogastroduodenoscopy (EGD), pH monitoring or other measures. Although empiric therapy may be used in patients with the typical symptoms of uncomplicated gastroesophageal reflux disease, the diagnosis should be confirmed if symptoms are persistent or refractory.

[H.sub.2] BLOCKERS

Patients with significant symptoms of gastroesophageal reflux disease are usually treated with a course of continuous "phase 2" medications, which typically include an [H.sub.2] blocker, with or without prokinetic agents (Figure 1). [H.sub.2] blockers reduce esophageal acid exposure by reducing gastric acid secretion and volume. Conventional dosages of [H.sub.2] blockers generally inhibit 60 to 70 percent of 24-hour acid secretion.(12)

Substantial evidence suggests that [H.sub.2] blocker therapy alleviates reflux symptoms in many patients and promotes healing of mild to moderate erosive esophagitis. Studies show that the therapeutic response depends primarily on the endoscopically determined grade or severity of the esophagitis and only secondarily on the duration of therapy.[13] Healing frequencies with cimetidine (Tagamet), totaling 800 to 1,600 mg daily in divided doses for six weeks, are typically 50 to 70 percent for minimal esophagitis but drop to 20 to 30 percent for circumferential erosions.[14] When treatment is extended to 12 weeks, healing rates increase to 80 to 90 percent and 40 to 50 percent, respectively, in most studies.

Comparable results are reported from most studies assessing equipotent dosages of the other [H.sub.2] blockers--ranitidine (Zantac), famotidine (Pepcid) and nizatidine (Axid)--for gastroesophageal reflux disease. Double-blind, randomized comparisons between these "standard-dose" regimens of the [H.sub.2] blockers are limited but do not demonstrate significant statistical differences in therapeutic outcome.

Most studies with [H.sub.2] blockers evaluate divided-dose regimens to inhibit both daytime and nocturnal acid secretion. Many patients experience daytime symptoms so predominantly that, theoretically, they would not be responsive to nocturnal administration of [H.sub.2] blockers. However, nocturnal acid reflux is more predictive of gastroesophageal reflux disease complications than daytime acid exposure, emphasizing that patients with severe disease need nocturnal medication despite predominantly daytime symptoms.

PROKINETIC AGENTS

Prokinetic drugs potentially reduce gastroesophageal reflux by two mechanisms: (1) increasing LES pressure and (2) accelerating gastric emptying. They also facilitate acid clearance from the esophagus by enhancing esophageal peristalsis.[15] Agents presently available in generic form include bethanechol (Urecholine), a cholinergic agonist, and metoclopramide (Reglan), a dopamine antagonist and cholinergic agonist. The effects actually produced by these drugs, however, appear to be limited. Although both agents enhance LES pressure, patients with the lowest resting pressure have the smallest increase in sphincter tone. Bethanechol does not appear to accelerate gastric emptying, and metoclopramide does not clearly improve esophageal acid clearance. The clinical efficacy of bethanechol and metoclopramide in the treatment of gastroesophageal reflux disease has not been consistently confirmed.

Bethanechol plus antacids has been shown to be more effective than antacid therapy alone in one of two studies.[16] Although metoclopramide at a dosage of 10 mg four times daily has reportedly improved reflux symptoms in two out of four studies, 24-hour acid contact time within the esophagus is not diminished with this dosage.[16]

Studies comparing bethanechol or metoclopramide with standard doses of [H.sub.2] blockers have demonstrated clinical outcomes equal to or less effective than outcomes with prokinetic agents.[17] Their unimpressive results, especially in promoting healing of erosive esophagitis, are compounded by the appreciable toxicity, including extrapyramidal reactions, of metoclopramide.[18]

Cisapride (Propulsid) has the broadest spectrum of action of the prokinetic drugs. Cisapride enhances the release of acetylcholine from postganglionic nerve endings in the myenteric plexus and is a serotonin type IV-receptor agonist. Several placebo-controlled studies have shown that cisapride alleviates reflux symptoms and promotes esophageal healing.[19] In direct comparative studies, cisapride is as effective as standard doses of cimetidine or ranitidine and is somewhat better than metoclopramide.[15] In addition, the side effect profile of cisapride is low; this drug should serve as the first choice among promotility agents. Erythromycin, in either low dosages (250 mg four times daily) or high dosages (500 mg four times daily), has little effect on acid exposure time and thus appears to have no important clinical role in therapy for gastroesophageal reflux disease.[20]

SUCRALFATE

Sucralfate (Carafate) is a sulfated disaccharide complex with aluminum hydroxide that has a minimal buffering effect in the stomach and does not appreciably alter gastric acid or pepsin secretion. It adheres to damaged tissue during its passage through the esophagus with swallowing and after reflux of gastric content. Sucralfate is most often given in dosages of 1 g four times daily. Some studies have reported no significant benefit of sucralfate suspension over placebo for symptom relief or healing. Other studies, however, have found short-term healing rates in mild-to-moderate esophagitis to be comparable to rates with standard dosages of cimetidine or ranitidine.[21]

COMBINATION MEDICAL THERAPY

Combining conventional antisecretory dosages of [H.sub.2] blockers with prokinetic agents does not necessarily enhance the clinical response achieved by monotherapy. Combination therapy with metoclopramide and cimetidine resulted in statistically significant (although clinically modest) enhancement of endoscopic healing (55 percent versus 42 percent) in one of two reports.[22] Cisapride has also been shown to significantly enhance the response to cimetidine alone.[23] However, combination therapy with sucralfate, 1 g three times daily, and cimetidine, 400 mg at night, provided no advantage over sucralfate at 1 g four times daily.[24]

Cimetidine, 300 mg four times daily, plus sucralfate, 1 g after meals and 2 g at bedtime, improved the endoscopically determined outcome of esophagitis more frequently than cimetidine alone, although fewer than 50 percent of patients in either group showed endoscopic improvement after 12 weeks, and total healing rates were not different.[25] Sucralfate, 1 g after meals, with ranitidine, 300 mg after dinner, was no better than sucralfate alone and produced complete healing in only,31 percent of patients after 16 weeks.[26]

Medical Therapy for Severe/Refractory Gastroesophageal Reflux Disease

In patients with severe esophagitis, healing rates of less than 50 percent have been reported with conventional [H.sub.2] blocker regimens of eight to 12 weeks.[13] Recently, several authors have reported that many of these patients tend to have higher basal acid outputs and more severe pretreatment amounts of acid reflux, and exhibit no or poor inhibition of gastric acid secretion with standard or higher dosages of [H.sub.2] blockers (i.e., ranitidine at 150 to 300 mg twice daily).[8,27] High dosages of ranitidine (up to 3,000 mg daily) were required to normalize esophageal acid exposure and promote endoscopic healing in this patient group.[28] Symptom relief and healing were achieved after the ranitidine was titrated to inhibit the basal acid output to less than 1 mEq per hour.[8,23]

Profound acid suppression has also been reported with proton pump inhibitors. Omeprazole (Prilosec) is the first drug of this class to be marketed. The drug irreversibly and noncompetitively inactivates parietal cell [H.sup.+]-[K.sup.+]-ATPase, the gastric proton pump located in the secretory apparatus of the parietal cell membrane. Omeprazole inhibits both basal and stimulated acid secretion. In most patients, a single daily dose of 20 to 30 mg inhibits 24-hour acid secretion by better than 90 percent. Compared with standard dosages of [H.sub.2] blockers with or without metoclopramide, an eight-week course of omeprazole, at 20 to 60 mg daily, produces more complete and longer-lasting acid suppression (thus normalizing esophageal acid exposure) and achieves superior rates of healing of erosive esophagitis (better than 71 percent).[29] Furthermore, patients with esophagitis refractory to more than 12 weeks' high-dose therapy with cimetidine (3.2 g daily) or ranitidine (300 to 900 mg daily) heal 92 percent of the time after 12 weeks' therapy with 40 mg daily of omeprazole.[30,31] Omeprazole at 40 mg daily produces slightly faster endoscopic healing rates than a dosage of 20 mg daily; however, overall healing at each dosage is equivalent to prolonged therapy (up to 12 weeks) in large study populations.[32] Therefore, initial therapy with 20 mg daily for at least four weeks is appropriate before resorting to higher dosages.[33]

Occasionally, patients are refractory to omeprazole therapy and demonstrate persistent esophageal acid exposure. This occurrence has been attributed to either an unusually short duration of gastric acid inhibition or a virtually absent inhibitory response to omeprazole as assessed by intragastric pH monitoring.[31] In selected persons, "high-dose" omeprazole therapy (up to 80 mg daily), administered in divided doses, may be required to adequately suppress 24-hour acid secretion. Recently it has been shown that high-dose omeprazole therapy (40 mg twice daily) for seven days may be used empirically as a diagnostic tool (the "omeprazole test" ), demonstrating a sensitivity of 83.3 percent.[34] In this test, if a patient's symptoms resolve following high-dose omeprazole therapy, the response suggests that gastroesophageal reflux disease is the cause of the symptoms. Otherwise, an alternate diagnosis should be considered.

At a dosage of 30 mg daily, lansoprazole (Prevacid), a newly developed proton pump inhibitor, is more effective than standard dosages of [H.sub.2] blockers in promoting healing of gastroesophageal reflux disease.[35] Although as effective as omeprazole in equivalent doses, lansoprazole may provide earlier symptom relief.[34] In standard dosages, both proton pump inhibitors appear to be more cost effective than [H.sub.2] blockers for long-term treatment.[3]

The proton pump inhibitors should be considered for treatment of gastroesophageal reflux disease in patients who are resistant to standard treatment with [H.sub.2] blockers. Side effects are minimal and, although much emphasis was placed initially on carcinogenic effects on the stomach during long-term therapy, no reports currently indicate such a complication in humans.

Maintenance Therapy

Most patients with gastroesophageal reflux disease remain symptomatic for years and usually continue taking medication, either on a regular basis or as needed. Patients with more significant disease are particularly prone to early relapse after discontinuing medical treatment, regardless of the therapy.[29] Maintenance therapy with lower dosages of [H.sub.2] blockers (cimetidine at 300 to 1,200 mg daily, ranitidine at 150 to 300 mg daily or famotidine at 20 to 40 mg daily) to prevent recurrence is generally disappointing.[13] Furthermore, patients with severe disease usually relapse even with high-dose [H.sub.2] blocker maintenance therapy.[27] However, several studies report endoscopic relapse rates of 25 to 34 percent over 12 to 24 months of maintenance therapy with omeprazole at 20 mg daily.[36,37]

In a study of omeprazole at 20 mg daily and ranitidine at 150 mg twice daily for maintenance therapy, 12-month relapse rates of 32 percent and 90 percent, respectively, were reported.[38] Most patients who reportedly relapsed with omeprazole at 20 mg daily rehealed with a dosage of 40 mg daily.

When used as maintenance therapy, cisapride has also been demonstrated to significantly increase symptomatic and endoscopic remission rates compared with placebo.[39] However, efficacy is unimpressive in patients with severe esophagitis before healing. Studies comparing cisapride with acid-suppressing agents as maintenance therapy have not been reported; however, a combination of cisapride and omeprazole seems to provide more effective maintenance therapy than omeprazole alone.(40]

Cost Considerations

The retail cost of a 30-day supply of omeprazole at 20 mg daily is slightly higher than the cost for standard doses of the [H.sub.2] blockers (Table 3). One researcher[41] hypothesized that the cost of overall medical care for gastroesophageal reflux disease with esophagitis after failure of phase 1 therapy would actually be significantly less with omeprazole than with ranitidine because of greater clinical efficacy, fewer complications and a reduced need for surgical intervention. Indeed, a prospective study randomizing patients with esophagitis and peptic stricture to treatment with omeprazole at 20 mg daily, ranitidine at 150 mg twice daily or famotidine at 20 mg twice daily reported a cost reduction with omeprazole therapy that was attributed to a decreased need for repeated esophageal bougienage.[42]

[TABULAR DATA 3 OMITTED]

Surgical Therapy

Long-term efficacy of antireflux surgery can be achieved in more than 80 percent of patients followed for an average of 6.6 years after Nissen fundoplication.(43) A Veterans Affairs' cooperative trial(44) compared medical and surgical therapies for complicated gastroesophageal reflux disease and concluded that surgery was more effective at one year of follow-up. Medical therapy was administered in a stepwise combination fashion with antacids, standard-dose ranitidine, sucralfate and metoclopramide.

Other studies have demonstrated that surgery confers better clinical results than [H.sub.2] blocker therapy in patients with gastroesophageal reflux disease-related asthma.[45] Trials comparing surgery and optimal medical management with a proton pump inhibitor have not been performed, but a cost-effectiveness analysis suggests that, in younger patients, surgery is advantageous when compared with a medical strategy that includes omeprazole.[46]

Although the availability of potent acid inhibitors has limited the use of surgery in patients with gastroesophageal reflux disease, the recent introduction of laparoscopic Nissen fundoplication has shifted attention back to surgical management. However, long-term outcome studies are still unavailable. Surgery should be considered in patients with severe complications, in those with refractory disease and in young adults with disabling symptoms who would require long-term aggressive medical management.

[Figure 1 ILLUSTRATION OMITTED]

REFERENCES

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Practice Parameters Committee of the American College of Gastroenterology. Arch Intern Med 1995;155:2165-73. [8.] Collen MJ, Lewis JH, Benjamin SB. Gastric acid hypersecretion in refractory gastroesophageal reflux disease. Gastroenterology 1990;98:654-61. [9.] Kitchin LI, Castell DO. Rationale and efficacy of conservative therapy for gastroesophageal reflux disease. Arch Intern Med 1991;151:448-54. [10.] McDonald-Haile J, Bradley LA, Bailey MA, Schan CA, Richter JE. Relaxation training reduces symptom reports and acid exposure in patients with gastroesophageal disease. Gastroenterology 1994;107:61-9. [11.] Dalton C, Becker D, Sinclair J, Castell D. Alginic acid is more effective than antacid in controlling upright gastroesophageal reflux [Abstract]. Am l Gastroenterol 1990;85:1217. [12.] Jones DB, Howden CW, Burget DW, Kerr GD, Hunt RH. Acid suppression in duodenal ulcer: a meta-analysis to define optimal dosing with antisecretory drugs. Gut 1987;28:1120-7. [13.] Koelz HR, Birchler R, Bretholz A, Bron B, Capitaine Y, Delmore G, et al. Healing and relapse of reflux esophagitis during treatment with ranitidine. Gastroenterology 1986;91:1198 205. [14.] Palmer RH, Frank WO, Rockhold FW, Wetherington JD, Young MD. Cimetidine 800 mg twice daily for healing erosions and ulcers in gastroesophageal disease. J Clin Gastroenterol 1990;12(Suppl 2):529-34. [15.] Ramirez B, Richter JE. Review article: promotility drugs in the treatment of gastro-oesophageal reflux disease. Aliment Pharmacol Ther 1993;7:5-20. [16.] Guslandi M, Testoni PA, Passaretti S, Masci E, Ballarin E, Comin U, et al. Ranitidine vs metoclopramide in the medical treatment of reflux esophagitis. Hepatogastroenterology 1983;30:96-8. [17.] Thanik K, Chey WY, Shak A, Hamilton D, Nadelson N. Bethanechol or cimetidine in the treatment of symptomatic reflux esophagitis: a double-blind control study. Arch Intern Med 1982;142:1479-81. [18.] Ganzini L, Casey DE, Hoffman WF, McCall AL. The prevalence of metoclopramide-induced tardive dyskinesia and acute extrapyramidal movement disorders. Arch Intern Med 1993,153:1469-75. [19.] Richter JE. Efficacy of cisapride on symptoms and healing of gastro-oesophageal reflux disease: a review. Scand J Gastroenterol 1989;165(Suppl):19-28. [20.] Champion G, Richter JE, Singh S, Schan C, Nellans H. Effects of oral erythromycin on esophageal pH and pressure profiles in patients with gastroesophageal reflux disease. Dig Dis Sci 1994,39:129-37. [21.] Elsborg L, Jorgensen F. Sucralfate versus cimetidine in reflux oesophagitis. A double-blind clinical study. Scand J Gastroenterol 1991,26:146-50. [22.] Lieberman DA, Keeffe EB. Treatment of severe reflux esophagitis with cimetidine and metoclopramide. Ann Intern Med 1986;104:21-6. [23.] Galmiche JP, Brandstatter G, Evreux M, Hentschel E, Kerstan E, Kratochvil P, et al. Combined therapy with cisapride and cimetidine in severe reflux oesophagitis: a double blind controlled trial. (jut 1988;29:675-81. [24.] Schotborgh RH, Hameeteman W, Dekker W, v.d. Boomgaard DM, Van Olffen GH, Schrijver, et al. Combination therapy of sucralfate and cimetidine, compared with sucralfate mono-therapy, in patients with peptic reflux esophagitis. Am J Med 1989; 86(Suppl 6A):77-80. [25.] Herrera JL, Shay SS, McCabe M, Peura DA, Johnson LF. Sucralfate used as adjunctive therapy in patients with severe erosive peptic esophagitis resulting from gastroesophageal reflux. Am J Gastroenterol 1990;85:1335-8. [26.] Vermeijden JR, Tytgat GN, Schotborgh RH, Dekker W, v.d. Boomgaard DM, van Olffen GH, et al. Combination therapy of sucralfate and ranitidine, compared with sucralfate monotherapy, in patients with peptic reflux esophagitis. Scand J Gastroenterol 1992;27:81-4. [27.] Bianchi Porro G, Pace F, Sangaletti O. Pattern of acid reflux in patients with reflux esophagitis "resistant" to H2-receptor antagonists. Scand J Gastroenterol 1990;25:810-4. [28.] Collen MJ, Johnson DA. Correlation between basal acid output and daily ranitidine dose required for therapy in Barrett's esophagus. Dig Dis Sci 1992; 37:570-6. [29.] Hetzel DJ, Dent J, Reed WD, Narielvala FM, Mackinnon M, McCarthy JH, et al Healing and relapse of severe peptic esophagitis after treatment with omeprazole. Gastroenterology 1988,95:903-12. [30.] Bardhan KD, Morris P, Thompson M, Dhande DS, Hinchcliffe RF, Jones RB, et al. Omeprazole in the treatment of erosive oesophagitis refractory to high dose cimetidine and ranitidine. Gut 1990;31:745-9. [31.] Koop H, Hotz J, Pommer G, Klein M, Arnold R. Prospective evaluation of omeprazole treatment in reflux oesophagitis refractory to H2-receptor antagonists. Aliment Pharmacol Ther 1990;4:593-9. [32.] Sontag SJ, Hirschowitz BI, Holt S, Robinson MG, Behar J, Berenson MM, et al. Two doses of omeprazole versus placebo in symptomatic erosive esophagitis: the U.S. multicenter study. Gastroenterology 1992;102:109-18. [33.] Bate CM, Booth SN, Crowe JP, Mountford RA, Keeling PW, Hepworth-Jones B, et al. Omeprazole 10 mg or 20 mg once daily in the prevention of recurrence of reflux oesophagitis. Solo Investigator Group. Gut 1995;36:492-8. [34.] Schindlbeck NE, Klausen-AG, Voderholzer WA, Muller-Lissner SA. Empiric therapy for gastroesophageal reflux disease. Arch Intern Med 1995;155:1808-12. [35.] Berstad A, Hatlebakk JG. Lansoprazole in the treatment of reflux oesophagitis: a survey of clinical studies. Aliment Pharm Ther 1993;7(Suppl 1):34-6. [36.] Stem DL, Simon TJ, berlin RG, et al. Controlling 24 hour esophageal acid exposure in patients with healed erosive esophagitis prevents endoscopic recurrence and symptomatic deterioration: results of a 6-month, randomized, double-blind, U.S., placebo-controlled trial comparing famotidine 20 mg bid and 40 mg bid [Abstract]. Gastroenterology 1991;100:A167. [37.] Lundell L, Backman L, Ekstrom P, Enander LH, Fausa O, Lind T, et al. Omeprazole or high-dose ranitidine in the treatment of patients with reflux oesophagitis not responding to "standard doses" of H2-receptor antagonists. Aliment Pharmacol Ther 1990,4:145-55. [38.] Koop H, Arnold R. Long-term maintenance treatment of reflux esophagitis with omeprazole. Prospective study in patients with [H.sub.2]-blocker-resistant esophagitis. Dig Dis Sci 1991;36:552-7. [39.] Blum AL, Adami B, Bouzo MH, Brandstatter G, Fumagalli I, Galmiche JP, et al. Effect of cisapride on relapse of esophagitis. A multi-national, placebo-controlled trial in patients healed with an antisecretory drug. The Italian Eurocis Trialists. Dig Dis Sci 1993;38:551-60. [40.] Vigneri S, Termini R, Leandro G, Badalamenti S, Pantalena M, Savarino V, et al. A comparison of five maintenance therapies for reflux esophagitis. N Engl J Med 1995;333:1106-10. [41.] Hillman AL, Bloom BS, Fendrick AM, Schwartz JS. Cost and quality effects of alternative treatments for persistent gastroesophageal reflux disease. Arch Intern Med 1992;152:1467-72. [42.] Marks R, Rizzo J, Champion G, et al. Efficacy and cost effectiveness of omeprazole in the treatment of patients with peptic strictures and esophagitis [Abstract]. Gastroenterology 1 993;104:A140. [43.] Martinez de Haro LF, Ortiz A, Parrilla P, Garcia Marcilla JA, Aguayo JL, Morales G. Long-term results of Nissen fundoplication in reflux esophagitis without strictures. Clinical, endoscopic, and pH-metric evaluation. Dig Dis Sci 1992;37:523-7. [44.] Spechler SJ. Comparison of medical and surgical therapy for complicated gastroesophageal reflux disease in veterans. The Department of Veterans Affairs Gastoesophageal Reflux Disease Study Group. N Engl J Med 1992;326:786-92. [45.] Larrain A, Carrasco E, Galleguillos F, Sepulveda R, Pope CE. Medical and surgical treatment of nonallergic asthma associated with gastroesophageal reflux. Chest 1991,99:1330-5. [46.] Coley CM, Barry MJ, Spechler SJ, et al. Initial medical v. surgical therapy for complicated or chronic gastroesophageal reflux disease: a cost-effectiveness analysis [Abstract]. Gastroenterology 1993;104:A5.

The Authors

RONNIE FASS, M.D. is assistant professor of medicine at the University of Arizona College of Medicine and director of &e Gastrointestinal Motility Laboratory at the Tucson Veterans Affairs Medical Center. Dr. Fass graduated from Ben Gurion University, Israel, and was chief resident in internal medicine at the University of Arizona Medical Center. He completed a fellowship in gastroenterology at the University of California, Los Angeles, School of Medicine.

LEE J. HIXSON, M.D. is currently in private practice in St. George, Utah Dr. Hixson graduated from the University of Utah, where he also completed a residency in internal medicine. Dr. Hixson completed a fellowship in gastroenterology at the University of Arizona Medical Center.

MICHAEL L. CICCOLO, M.D. is currently a fellow in cardiothoracic surgery at the University of Southern California School of Medicine, Los Angeles. After graduating from the University of Iowa College of Medicine, Iowa City, Dr. Ciccolo completed a surgical residency at the University of Arizona Medical Center.

PAUL GORDON, M.D. is associate professor and co-head of the Department of Family and Community Medicine at the University of Arizona School of Medicine. Dr. Gordon graduated from Mount Sinai School of Medicine of the City University of New York, N.Y., and completed a family medicine residency at the University of Rochester (N.Y.) School of Medicine and Dentistry. He also completed a faculty development fellowship at the University of Arizona Medical Center

GLENN HUNTER, M.D. is professor of surgery at the University of Arizona Medical Center. He graduated from the University of Capetown, South Africa, and completed a residency and a fellowship in general and vascular surgery at the University of Arizona Medical Center.

WILLIAM RAPPAPORT, M.D. is associate professor of surgery at the University of Arizona College of Medicine. After graduating from the University of Miami (Fla.) School of Medicine, he completed residencies in pediatrics at Mount Sinai School of Medicine of the City University of New York, in general surgery at the University of Cincinnati (Ohio) College of Medicine, and in plastic surgery at the University of Oklahoma College of Medicine, Oklahoma City

Address correspondence to Ronnie Fass, M.D., GI Section (111G-1), Tucson Veterans Affairs Medical Center, 3601 S. 6th Ave., Tucson, AZ 85723.

2005-12-30T06:02:00.000-05:00

Byline: Mayo Clinic

ROCHESTER, Minn., May 9 (AScribe Newswire) -- Mayo Clinic plastic surgeons report that surgery to remove excess skin and fat in the upper arm, known as an "arm lift," is generally low risk. Minor complications may arise in approximately 25 percent of cases.

"We concluded that an arm lift is a safe procedure, but there are complications associated with it that surgeons and patients should be aware of," says James Knoetgen, III, M.D., Mayo Clinic plastic surgeon and lead study investigator. "Overall, the complication rate is relatively low, and the large majority of complications are minor. The only concerning complication we encountered in our study was injury to or irritation of sensory nerves in the arm that can cause numbness in the forearms, and rarely, pain in the hand and forearm."

In the Mayo Clinic study, the types of complications found to arise following arm lift surgery included fluid collections under the skin (10 percent), poor scarring (10 percent), skin infection (7.5 percent), abscesses under the skin (2.5 percent) and wound separation (7.5 percent). Nerve injuries occurred in 5 percent of the patients; one patient experienced prolonged numbness of one forearm and hand, and another patient developed pain in one forearm and hand. None of the patients required operative treatment for the complications.

Of the 40 patients studied, five had parts of their arm lifts revised, four to make changes in the skin appearance and one to have arm liposuction.

Dr. Knoetgen and Steven Moran, M.D., also a Mayo Clinic plastic surgeon, undertook this research to better understand the complications and outcomes of arm lift surgery, indicates Dr. Knoetgen.

In addition to aesthetic benefits, arm lifts can provide functional benefits for some patients. Dr. Knoetgen explains that in massive weight loss patients, an arm lift can help treat rashes that have developed due to excess upper arm skin sticking to the skin of the armpit and chest. It may also improve ability to exercise and make clothes fit better.

According to the American Society of Plastic Surgeons' (ASPS) statistics, ASPS member surgeons and other certified physicians performed 9,955 arm lifts in 2004. Of these arm lifts, 4 percent were performed on males and 96 percent on females. In addition, the society's statistics indicate a 2845 percent increase in upper arm lift surgeries from 2000 to 2004.

Dr. Knoetgen attributes the rise of this surgery's popularity primarily to the growth in weight loss surgeries such as gastric bypass surgery, since massive weight loss typically results in large amounts of excess skin. He also points out, however, that recently he has witnessed an increased interest in this surgery from non-massive weight loss patients.

This study involved a retrospective review examining all arm lift (brachioplasty) procedures performed between 1988 and 2004 at Mayo Clinic in Rochester, Minn. All of the 40 patients were female, with an average age of 47. Of these, 76 percent underwent arm lift surgery following significant weight loss, 74 percent of whom had gastric bypass surgery. The surgical technique utilized in all patients involved removal of skin and fat skin from the inner side of the upper arm. The patients' arm lift outcomes were studied an average of 50 months following surgery.

These findings will be presented in an abstract at the American Association of Plastic Surgeons 84th Annual Meeting at the Hyatt Regency at Gainey Ranch in Scottsdale, Ariz.

- - - -

CONTACT: Lisa Lucier, Mayo Communications, (000)-000-0000 (days), (000)-000-0000 (evenings), newsbureau@mayo.edu

VIDEO ALERT: Video, including sound bites from a subject expert and patient, plus surgical B-roll, are available through Pathfire's Digital Media Gateway (DMG). See end of this release for details.

NOTE TO EDITORS: Mayo Clinic is now using Pathfire's Digital Media Gateway (DMG) for video news release distribution, to streamline our services and provide content that is easily accessible as needed. On the DMG main page, look for the Mayo Clinic branded page in the left navbar, or click on the VNF Master Locator and search for MayoClinic0024. If you have questions or problems in locating the story, contact Pathfire Customer Support at (000)-000-0000 or support@pathfire.com.

2005-12-26T12:54:00.000-05:00

Byline: PAT HAGAN

PATIENTS with leg ulcers could soon be given an appointment with a mobile phone instead of a doctor. A new study shows medics can diagnose the ulcers and chronic wounds just as well when images are taken on a camera phone and emailed to them.

The breakthrough could mean many elderly patients get the diagnosis and treatment they need without having to leave home.

Nurses carrying out domestic visits take a picture of the wound using their mobile and forward it to a specialist at the hospital.

Research shows the images are good enough for doctors to be able to determine how bad it is and what therapy is needed.

The latest results, published in the journal Archives of Dermatology, provide another example of how high-tech mobiles can be used by doctors.

Staff at Royal Glamorgan Hospital, Wales, are trialing picture phones in a bid to cut down treatment times for patents with broken or fractured bones.

When a specialist is not available to make an instant diagnosis, junior doctors use mobiles to take a snap of the X-ray and email it straight to a consultant's phone.

The technology has been useful for difficult or multiple fractures, where a highly-trained eye is needed to interpret X-ray results.

Now a team of researchers from the University Hospital of Geneva has discovered phones can also save money by reducing the number of patients visiting hospital.

They studied 61 people with leg ulcers to see if they could prevent them having to go to a clinic to see a doctor. Leg ulcers are usually caused by poor circulation of blood and are often due to diabetes, cardiovascular disease or tumours. Surgery and blood clots can also be to blame.

As the skin becomes deprived of oxygen, it can crack and form wounds that fail to heal. These need regular care that may involve cleaning the wound, giving drugs to reduce inflammation and changing dressings.

Some ulcers need an operation to improve blood flow or to cover the hole with plastic surgery.

Regular inspections by a specialist are vital to limit the risk of infections and complications. But getting to the clinic can be an ordeal for many patients.

The Swiss researchers gave a group of doctors images of ulcers and wounds taken by a camera phone and asked them for a diagnosis and recommended treatment.

A separate group of doctors examined the same ulcers in person. The results were analysed and the two groups were almost identical in their assessments.

Their research report said: 'We show that telemedicine for chronic wounds is feasible using new generation mobile phones and email.'

2005-12-23T08:13:00.000-05:00

AP Online

08-06-2004

Dateline: NEW YORK

Clarence Aguirre recovers in the pediatric intensive care unit Thursday, Aug. 5, 2004, after a team of surgeons successfully separated him from his conjoined twin Carl in a 17 hour operation, at the Childrens Hospital at Montifiore in the Bronx, New York. (AP Photo/Montefiore Medical Center, Gary D. Bramnick)

With a 17-hour operation and its one nasty surprise behind them, the surgeons who separated 2-year-old conjoined twins said Thursday that it will be days before they can see how the boys respond to their transformation.

As the doctors spoke at a news conference at Montefiore Medical Center in the Bronx, Carl and Clarence Aguirre, who had been connected at the tops of their heads until Wednesday night, slept the day away upstairs, side by side instead of head to head.

Louis Singer, chief of pediatric intensive care at Montefiore's Children's Hospital, said the boys, who are from the Philippines, probably would be kept sedated through the weekend to help them heal. Doctors earlier had said the boys were expected to awaken Thursday.

The hospital continued to describe the boys' condition as "strong and stable," and its president, Dr. Spencer Foreman, declared the separation a success.

Doctors performed four major surgeries since October to gradually separate the boys, instead of the marathon sessions used in previous separations of conjoined twins.

"A huge step forward in this remarkable process has been accomplished," Foreman said. "We hope that Carl and Clarence will now begin to thrive as two separate and unique individuals."

Dr. James Goodrich, the neurosurgeon who led the operating team, said surgeons discovered that a 2-square-inch area of the boys' brains at the back of the heads was fused just as they thought they were nearing separation.

Doctors had expected the brains to be abutting, but they were "anatomically linked," Goodrich said at a hospital news conference.

"Obviously the brains were talking to each other," he said, meaning working jointly in some way.

By referring to three-dimensional images created in advance and following the contours they could see, the doctors manipulated the brains apart without resorting to an incision, Goodrich said. But he said fused brains cannot be separated "without some consequence."

"The hope is that the consequence is minimum at best," he said.

Goodrich said it would be "at least a week to 10 days before we can really assess what changes have taken place." He said he was encouraged that brain swelling and blood loss were minimal, often a sign that brain damage has been avoided.

He said twins joined at the head have never been separated without at least one suffering brain damage.

He added, "Would I do it this way again? Absolutely yes."

After the separation, Goodrich and the boys' plastic surgeon, Dr. David Staffenberg, started covering the brains, leaving reconstruction of the skulls for later.

The coverings included some oddities _ a material made from pigs' intestines was used to augment a membrane called the dura, and part of Clarence's scalp and hair was placed atop Carl's head and vice versa, Staffenberg said.

Goodrich and Staffenberg said they will be fascinated to see how Carl and Clarence react to the sight of each other. Doctors used mirrors and Velcro-headed dolls in their efforts to prepare the boys.

"There has to be enormous psychological import," Goodrich said. "But obviously they can't tell us."

Goodrich said the staff will be on the alert for any infection in the boys, leaks of spinal fluid and accumulations of liquid on the brain.

Staffenberg said that when the boys have healed enough, they'll go back into physical therapy at Blythedale Children's Hospital in Valhalla, where they and their mother, Arlene Aguirre, have been living between surgeries at Montefiore. Both hospitals and the doctors have donated their services.

Staffenberg said the rebuilding of the skulls will be done in two or three stages. It will be delightful, he said, to have "Carl and Clarence in the operating room as separate little boys."

___

On the Net:

Montefiore Medical Center: http://www.montefiore.org

Copyright 2004, AP News All Rights Reserved

2005-12-12T22:36:00.000-05:00

Byline: By Samantha Booth

THE world has changed a lot since the first edition of the Guinness Book Of Records was published back in 1955.

And the 2006 edition of the best-selling book - launched yesterday - reflects the trends and scientific advances of the modern world, alongside the traditional records relating to size, speed and stamina.

Here are some of the best new entries. Most plastic surgery:American Cindy Jackson has spent pounds 53,148 on 47 cosmetic ops since 1988.

Oldest woman to fly in zero gravity: Dorothy Simpson, from America, aged 79 years 237 days.

Longest surviving triple heart-bypass patient:Brit Richard Smith had the op in February 1978and lived for another 26years93 days.

Driving to the highest altitude: A Volkswagen Toureg SUV was driven to an altitude of 19,950ft on the slopes of a volcano on the Chile-Argentinian border.

Most casinos played in 24 hours: In March 2004,British brothers Martin and David Lawrance visited 55 in 24 hours in Las Vegas.

Most expensive omelette: The Zillion Dollar Lobster Frittata at Norma's restaurant in Le Parker Meridien Hotel, New York, costs $1000 (pounds 530) Most popular cosmetic procedure:Botox.It accounted for 14.73 per cent of all aesthetic plastic surgeries in 2003.

Most gender reassignment surgery: Fulvia Celica Siguas Sandoval of Peru has had 64 ops to complete his sex change.

Bras unhooked in a minute: Brit Chris Nicholson unhooked 20,using onehand Largest mobile phone: It measures 6.7 ft x 2.7ft x1.5ft and is fully functional Mostdurablemobilephone number:David Conorno, from America,hasownedandused the samenumber since August 1985Largest online community: Sony PlayStation2 hadmore than 1.4 million registered online users in August 2004Largest speeding fine: Jussi Salonja,of Finland,was fined pounds 116,000 in February2004 for doing50mph in a25mph zone.

Largest criminal DNA database: The UK's database contained 2,527,728 profiles in March 2004Smallest mammalused to detect land mines:AGambian giant pouch rat measuring76cm long,including the tail.

Most digital artists on a film: Sky Captain And The World Of Tomorrow had 320 visual effects artists working on it.

Most expensive TV advert:Baz Luhrmann's four-minute ad for Chanel No.5 perfume,starring Nicole Kidman,costpounds 18 million to make in 2004.

Biggest-selling download single in a week: Dogz Don't Kill People Wabbits Do by Mouldy Looking Stain sold more than 7000 in the UK in a week in October 2004.

Biggest-selling download single in the UK:Amarillo,by Tony Christie featuring Peter Kay,has sold 57,804 downloads to date.

Fastest 100 metres on a spacehopper: Ashrita Furman did the distance in 30.2 seconds.

Balloon dog made behind the back:Brit Craig Keith managed the feat in just 9.26 seconds last year.

Heaviest weight lifted with tongue: Brit Thomas Blackthorne lifted 24lb 3oz.

Most expensive ice-cream sundae:the Serendipity Golden Sundae from Serendipity restaurants in New York cost $1000 (pounds 530) in 2004.

Most crisp packets: Bernd Sikora, from Germany, owns 1482 from 43 countries

CAPTION(S):

LONG AND SHORT OF IT: Xi; Shun, 53, listed as the tallest man, and Kiran Shah, 52, the smallest stuntman, at the launch of the book outside the Houses of Parliament

2005-12-10T03:00:00.000-05:00

Byline: Mayo Clinic

Of the 40 patients studied, five had parts of their arm lifts revised, four to make changes in the skin appearance and one to have arm liposuction.

Dr. Knoetgen and Steven Moran, M.D., also a Mayo Clinic plastic surgeon, undertook this research to better understand the complications and outcomes of arm lift surgery, indicates Dr. Knoetgen.

These findings will be presented in an abstract at the American Association of Plastic Surgeons 84th Annual Meeting at the Hyatt Regency at Gainey Ranch in Scottsdale, Ariz.

- - - -

CONTACT: Lisa Lucier, Mayo Communications, (000)-000-0000 (days), (000)-000-0000 (evenings), newsbureau@mayo.edu

VIDEO ALERT: Video, including sound bites from a subject expert and patient, plus surgical B-roll, are available through Pathfire's Digital Media Gateway (DMG). See end of this release for details.

2005-12-01T00:12:00.000-05:00

Byline: Dana Silber

PLASTIC FANTASTIC

The right frames can accomplish so much more than jewelry or the hautest bag--which explains why even women with flaw less vision are snapping them up. "It really is fashion for the face," says eyewear designer Robert Marc. Playful plastic frames in a medley of colors and tones enable ALICIA KEYS, Angelina Jolie, Eva Longoria and other stars to make a vivacious statement. "Choose a hue that complements your own coloring," advises Larry Leight, chief designer at Oliver Peoples. "Find a shade that is in harmony with your hair, eye color and daily makeup palette."

1 Plastic, Paul Smith Spectacles, $245; 888-568-1655 for stores. 2 Italian plastic, Christian Roth Eyewear, $210; at Artsee Eyewear, 212-414-0900. 3 Plastic, Ray-Ban, $107; at Lenscrafters or rayban.com. 4 Plastic tortoiseshell, L.A. Eye-works, $275; 323-931-7795 or laeyeworks.com. 5 Plastic, Gucci, $245; 800-289-3937 or docoptical.com. 6 Plastic, Robert Marc, $345; 212-675-5200. 7 Plastic, Prada, $189; at luxottica.com. 8 Zyl plastic with crystal accents, Jessica McClintock Eyewear, $80-$100; 800-645-3733. 9 Zyl plastic, Paul Frank, $150; at paulfrank.com. 10 Translucent plastic, Donna Karan, $199; at luxottica.com.

BRAINY BEAUTY

Professorial styles like these combination rimless and plastic or metal frames ensure that such celebrities as FELICITY HUFFMAN display their visionary side with just one glance. The same idea translates to the workplace: They're an effective tool to help get your point across in important meetings. Select a fetching style that enhances your face, personality and IQ. Can you wear such a cerebral look seven days a week? "These definitely go beyond the office," Marc says. "In fact, there's something very bold and sexy about this look, especially when you whip them off for effect."

1 Metal, Lacoste, $175; at Max & Co. Eyewear, 714-662-1222. 2 Metal, Alain Mikli, $420; 212-472-6085 or mikli.com. 3 Metal, Selima Optique, $275; at Selima Optique, 212-343-9490. 4 Plastic, Ralph Lauren, $220; 800-289-3937 or docoptical.com 5 Plastic, Oliver Peoples by Larry Leight, $310; 888-568-1655 or oliverpeoples.com. 6 Titanium, Morgenthal Frederics, $385; 212-838-3090 or morgenthalfrederics.com. 7 Plastic, Tommy Hilfiger, $165; 888-688-8948. 8 Plastic, Miu Miu, $159; at Sunglass Hut stores. 9 Titanium, Face a Face, $450; 888-388-3223 or faceaface-paris.com. 10 Titanium, Sama Eyewear, $395; at Destination Sama, 877-788-7262.

OFF THE RIM

Lasik surgery be damned. This ophthalmic look has been gaining in popularity ever since Nicole Kidman donned a pair of rimless specs for The Interpreter. Other fans include Jennifer Aniston and JENNIFER GARNER. The advantage to having no frame is that the glasses won't overpower your features, yet interesting lenses impart a cool, modern edge. Can such a minimalist approach work for evening? "These are perfect for dressing up because they're very subtle, so they'll blend in and won't detract from your makeup and clothes," says Richard Morgenthal, designer for Morgenthal Frederics. --Dana Silber

1 Metal, Lunor, $395; at Robert Marc, 212-675-5200. 2 Rimless with citrine and aquamarine semiprecious stones, Miyagi Eyewear, $199; 800-678-9244 for stores. 3 Rimless with metallic bronze, Brooks Brothers, $170; at Lenscrafters or lenscrafters.com. 4 Metal with rhinestones, Fendi, $130; 800-544-1336 or marchon.com. 5 Metal, Chanel, $205; 800-550-0005. 6 Rimless, Dior, $415; 800-289-3937. 7 Metal, Michael by Michael Kors, $199; 800-544-1336 or marchon.com. 8 Titanium, Silhouette, $268; 800-223-0180 for stores. 9 Titanium and acetate, Kata Eyewear, $315; at City Optix, 415-921-1188. 10 Rimless, DKNY, $139; at luxottica.com.

2005-11-28T13:53:00.000-05:00

Armenian Reporter, The

04-24-2004

A significant number of Armenians living in America are adopting the

practice of circumcision - a procedure that historically has not been a

custom among Christian Armenians. The following is an article based on the

review and analyses of books, research papers, articles, as well as

personal interviews with physicians, literary figures, human rights

activists, and members of the Armenian and Jewish communities. I also

collected data from day care centers and practicing Armenian pediatricians,

which revealed a 30-40% circumcision rate among Armenian children. (The

national incidence with U.S. males is 60%.).

The practice of circumcision among Armenians serves no religious purpose

and is mainly performed for "hygienic" reasons. Some parents have been

victims of negligent doctors who circumcised children at the hospitals

without the parents' informed consent. Others have been solicited by

hospital staff, and have fallen prey to the institution that promotes the

procedure for financial reasons.

Still other people in our community seem to want to assimilate to the

dominant American culture by "embracing its custom of circumcision. While

routine circumcision of male infants has been a much-debated issue in the

US. for many years, it is now being questioned in an unprecedented way.

Nonetheless, it remains an especially uncomfortable topic of discussion

among most Armenians: The subject of circumcision, however, is a rather

complex multidimensional social issue that ought to be discussed from the

perspective of history, culture, religion, and medicine. It is also a

sexual and human rights issue. In short, it requires the attention of

medical professionals, lawyers, educators, ethics scholars, and religious

leaders. Their collective knowledge and expertise would contribute a sound

foundation upon which we can begin raising awareness regarding this

controversial cultural introjection that has been neglected for far too

long.

ORIGINS OF CIRCUMCISION

Despite the common belief that circumcision was invented by Jews, it is

known from history that it originated in different areas of Africa and

dates back at least 5,000 years, appearing in Egyptian representations of

Pharaonic times. Thus, both Jews and Arabs learned circumcision in Egypt.

An array of explanations for the motives behind the practice has been

offered by historians, anthropologists, and other scholars. As described in

Circumcision of Male Infants Research Paper (Queensland Law Reform

Commission. Brisbane, 1993), the roots and motives of circumcision are

barbaric and cruel. In fact, circumcision is believed to have been applied

as a castigatory measure, and as a mark of slavery. Some anthropologists

also speculate that circumcision is attenuation of human sacrifice,

relating it to the practice of cutting off the entire penis, which was

offered as a sacrifice to the gods, or were used as war trophies. Some

warriors offered the genitalia of their enemies as trophies to the girls

they chose to marry.

Other interpretations of the motives of the practice have been: rites of

passage, tribal integration; gender identity; desensitization of the sexual

organ to moderate sexual activity, and thus, to perfect morality; cultural

assimilation, as well as hygienic and medical reasons. I will narrow down

my discussion on the sexual aspect of the procedure, assimilation and

acculturation issues, as well as the claimed "hygienic" and "medical"

reasons.

Moses Maimonides, the famed 12th-century Jewish rabbi, physician and

philosopher, wrote in his book The Guide of the Perplexed (University of

Chicago, 1963) Part III, Chapter 49, Page 609:

"... with regard to circumcision, one of the reasons for it is, in my

opinion, the wish to bring about a decrease in sexual intercourse and a

weakening of the organ in question, so that this activity be diminished and

the organ be in as quiet a state as possible. ... this commandment has not

been prescribed with a view to perfecting what is defective congenitally,

but to perfecting what is defective morally. The bodily pain caused to that

member is the real purpose of circumcision...The Sages, may their memory be

blessed, have explicitly stated: It is hard for a woman with whom an

uncircumcised man has had sexual intercourse to separate from him. In my

opinion this is the strongest of the reasons for circumcision."

MASTURBATION HYSTERIA IN THE VICTORIAN ERA

The non-religious practice of circumcision was introduced into secular

society and medically popularized in the U.S. and Britain over a century

ago in a period of time often retrospectively referred to as "the

masturbation hysteria." During my interview with Mark D. Reiss, MD, Vice

President of Doctors, Opposing Circumcision (D.O.C.), he discussed the

origins of circumcision practice in the Victorian era, when it was falsely

thought that masturbation caused insanity, epilepsy, paralysis, bed

wetting, blindness, asthma, rheumatism, curvature of the spine, alcoholism

and criminality. By circumcising, Victorian doctors hoped to eliminate

these dreaded diseases and conditions. However, it is now known that

circumcision does not prevent masturbation, or the above-mentioned

conditions, but rather only serves to make sexual functioning more

difficult.

MODERN PRACTICE OF CIRCUMCISION

In the early 20th century, circumcision was claimed to be more "hygienic"

and became a routine procedure in the U.S. and continued to increase after

the mass military circumcisions during WW I, and WW II, and the Vietnam

War. During this period, the incidence of circumcision was dramatically

increased and reached its peak in 1979, when 85-90% of American boys were

circumcised. Circumcision is far less common among other industrialized

countries, as well as in the non-Islamic regions of Asia (around 10-15%;

Circumcision Reference Library, 2003). The U.S. is the only country in the

world that routinely circumcises most of its male infants for nonreligious

reasons. Proponents of the procedure cite potential health benefits, such

as lowered risk of urinary tract infections (UTI), penile and cervical

cancer, human papilloma virus (HPV), as well as reduction of sexually

transmitted diseases (STDs).

Conversely, anti-circumcision activists oppose the removal of any healthy,

functional part of a human body as a means of disease control. Moreover,

the American Academy of Pediatrics states (1999) that "... these data are

not sufficient to recommend routine neonatal circumcision" and "...there is

no absolute medical indication for routine circumcision." Likewise, the

American Medical Association (Complete Medical Encyclopedia, 2003) states:

"There is no medical reason for routine circumcision of infants."

In fact, no medical organization in the world recommends routine

circumcision of infant boys. Many have specific statements arguing against

circumcision, including the American Academy of Pediatrics, the British

Medical Association, as well as the medical associations of other European

countries, Canada, and Australia.

In the face of the absence of medical indication, circumcision practice

continues, and those who promote it certainly gain financially. The

American Academy of Pediatrics states that each year, "1.2 million newborn

males are circumcised in the United States annually at a cost of between

$150 and $270 million." That estimate does not include hospital and nursing

fees, medical supplies, and expenses that arise as the result of

complications. The primary beneficiary of circumcision, thus, is not the

child, not the parent, but the medical community, which is involved in a

lucrative multimillion-dollar business.

CIRCUMCISION AND HIV

The latest renewed attention toward the correlation between HIV/AIDS

epidemic and circumcision status comes at a time when claims for medical

benefits have been losing stance for decades. Studies claim that HIV

infection rates are much lower in some West African nations, where

circumcision is common, than in some South and East African nations, where

circumcision is rare. However, since most of the circumcised men in the

study are Muslim, it is unclear whether circumcision status or variables

like sexual behavioral patterns typical of Islam play a role in the

protective effects.

Secondly, the U.S. has one of the highest circumcision rates among the

industrialized nations and also the highest HIV rate. Obviously,

circumcision did not protect Americans from HIV infection. On the other

hand, circumcision rates are low in Europe, as are HIV infection rates.

The American Medical Association (Report on Neonatal Circumcision, online)

has stated, "Regardless of these findings, behavioral factors are far more

important risk factors for acquisition of HIV and other sexually

transmittable diseases than circumcision status, and circumcision cannot be

responsibly viewed as 'protecting' against such infections."

Marilyn Milos, the co-founder and director of National Organization of

Circumcision Information Resource Centers (NOCIRC), wrote to me in her

email letter, "The scare tactics are always consistent with the dreaded

disease of the times." "There was a penile cancer scare in the '30s; a

cervical cancer scare in the '50s; and the sexually transmitted disease

scare of the '60s."

WHERE IS MY FORESKIN?

Does the foreskin have any function at all, or has evolution failed? Didn't

evolution determine that the male mammals' genitals be an internal and not

an external organ, sheathed in a protective foreskin? Is a foreskin just a

"dead piece of skin?" "Is it nature's defect?"

In his article "The Case against Circumcision" (Mothering Magazine, Winter

1997), Dr. Paul Fleiss writes that most American textbooks do not even

mention the foreskin and illustrate the human penis circumcised, as if that

is its natural state. "Millions of years of evolution have fashioned the

human body into a model of refinement, elegance, and efficiency, with every

part having a purpose," writes Dr. Fleiss. Furthermore, he explains that

the foreskin is an essential part of human sexual anatomy, containing

greater concentration of blood vessels and nerve endings than any part of

penis. The foreskin, he explains, is a uniquely specialized, sensitive, and

functional erogenous organ of touch. The foreskin removed by circumcision

represents about 80% (depending on the circumcising doctor) of the penile

skin. Dr. Fleiss concludes that circumcision denudes, desensitizes, and

disables the penis. It also destroys nature's design of the double-layered

sheath that facilitates the "gliding mechanism" during intercourse.

Garry Harryman, the coordinator for the Southern California chapter of the

National Association of Restoring Men, writes in his article titled "What

is Lost to Circumcision": "Contrary to pseudo-medical myth, the natural

penis with its foreskin intact is not defective or dangerous and does not

require urgent surgical correction. Through four thousand millennia of

trial and error, Nature has perfected human sexuality as a physical

collaboration between two exquisitely complementary designs. The vagina was

not designed to accommodate a dry, keratinized, and immobile penis."

He calls circumcision a "mutilating radical sexual surgery euphemistically

called 'male circumcision.'"

"[Infant] circumcision requires that the surgeon tear the skin from the

sensitive glans to permit removal." Dr. George Denniston, President of

Doctors Opposing Circumcision (D.O.C.), explains in his interview, "As a

result, scarring occurs, the surface of the glans thickens, and

keratinization occurs." Dr. Denniston's advice is to leave the foreskin to

fulfill its several functions. In fact, the American Academy of Pediatrics

pamphlet on "Care of the Uncircumcised Penis; Guidelines for Parents,"

follows:

"Care of the uncircumcised boy is quite easy. "Leave it alone" is good

advice.

External washing and rinsing on a daily basis is all that is required. Do

not retract the foreskin in an infant, as it is almost always attached to

the glans. Forcing the foreskin back may harm the penis, causing pain,

bleeding, and possibly adhesions. The natural separation of the foreskin

from the glans may take many years."

Many parents, whom I talked to explain their choice of circumcision with

claims of "cleanliness." However, what makes us humans think that part of

our body is not clean, and needs further modification? In the

above-mentioned article, Dr. Fleiss writes:

"The white emollient under the child's skin is called smegma. Smegma is

probably the most misunderstood, most unjustifiably maligned substance in

nature. Smegma is clean, not dirty, and is beneficial and necessary. It

moisturizes the glans and keeps it smooth, soft, and supple. Its

antibacterial and antiviral properties keep the penis clean and healthy.

Forcibly retracting and washing a baby's foreskin destroys the beneficial

bacterial flora that protect the penis from harmful germs and can lead to

irritation and infection. The child's foreskin, like his eyelids, is

self-cleansing.

In fact, according to Dr. Denniston, the foreskin is there to protect the

glans from the exposure of feces and urine in the infancy. With

circumcision this protection is gone.

"Penile hygiene will later become a part of a child's total body hygiene,"

the American Academy of Pediatrics states, "including hair shampooing,

cleansing the folds of the ear, and brushing teeth. At puberty, the male

should be taught the importance of retracting the foreskin and cleaning

beneath during his daily bath."

COMPLICATIONS

As with all kinds of surgery, circumcision has some risks. Here are some of

the complications of circumcision from the report of the American Medical

Association, (1999).

"Bleeding and infection, occasionally leading to sepsis, are the most

common adverse events requiring treatment" reads the report. "Other

untoward events can result from taking too much skin from the penile shaft

causing denudation or rarely, concealed penis. Other postoperative

complications include formation of skin bridges between the penile shaft

and glans, meatitis and meatal stenosis, chordee, inclusion cysts in the

circumcision line, lymphedema, hypospadias and epispadias, and urinary

retention. Case reports have associated circumcision with other rare but

severe events including scalded skin, necrotizing fasciitis, sepsis and

meningitis, urethrocutaneous fistulas, necrosis (secondary to

cauterization), and partial amputation of the glans penis."

There is no data as to how many deaths a year occur as the result of

circumcision. "Circumcision kills an unknown number of U.S. infants every

year," writes Gary Harryman. "The cause of these deaths," he continues, "is

a fact the billion-dollar-per-year circumcision industry willfully obscures

and conceals...Every year boys lose their penises altogether from 'botched

circumcisions.' They are then 'sexually reassigned' by transgender surgery

and must live their lives as females." Obviously, any potential benefits of

circumcision are far outweighed by its risks and drawbacks.

Dr. Vigen Zargarian, an Iranian-Armenian pediatrician in practice for 27

years, has dealt with the circumcision issue throughout his long experience

in pediatrics. "I have seen many circumcision procedures performed both in

Iran and the U.S.," explains Dr. Zargarian in his interview. "I have seen a

child die in 24 hours from gangrene and sepsis caused by necrotizing

fasciitis (flesh-eating bacteria), right in front of my eyes."

BEHIND CLOSED DOORS

Most parents are ill informed about the short-term and long-term effects of

circumcision on the child. Dr. Zargarian explained how the typical

circumcision procedure is carried out in American hospitals. "As usually

performed without analgesia, circumcision is very painful," says Dr.

Zargarian. "In fact, children feel excruciating pain, and local anesthetics

are not effective enough," he explains. "This procedure is agonizing; the

powerless child is taken away from his parents, stripped naked, and put on

a 'circumstraint' board. His arms and legs are fastened tightly with

straps. The whole scene looks like a crucifixion." In fact, research shows

that, during circumcision, the infant "withdraws into a state of neurogenic

shock (coma), due to sudden massive pain," which in fact is misinterpreted

as being "quiet" or "falling asleep." (Dr. George Denniston, Circumcision

Quiz, online).

"Parents should know what lies ahead for their tiny infant," insists Dr.

Zargarian, "and the best way to educate them about this procedure is to

have them watch a video." (The two films that are highly recommended are:

"It's a Boy!" and Whose Body, Whose Rights) However, the idea of observing

a circumcision is not acceptable to many parents. Meanwhile, the baby has

to undergo a procedure his own parents cannot stand to watch. "If parents

have a chance to ever observe the procedure," Dr. Zargarian adds, "I am

almost certain that they will not let their child go through it."

Circumcision Resource Center (Mothers who Observed Circumcision) reports

the numerous testimonies of mothers who have observed circumcision. One

mother writes:

"The screams of my baby remain embedded in my bones and haunt my mind."

She added later, "His cry sounded like he was being butchered. I lost my

milk."

Here is how a mother felt after circumcision of her son:

"It was as close to hell as I ever want to get!"

Another mother shares her deep feelings of regret:

"My tiny son and I sobbed our hearts out...After everything I'd worked for,

carrying and nurturing Joseph in the womb, having him at home against no

small odds, keeping him by my side constantly since birth, nursing him

whenever he needed closeness and nourishment - the circumcision was a

horrible violation of all I felt we shared. I cried for days afterward."

A mother noted that she still felt pain recalling the experience about a

year later. She wrote to her son:

"I have never heard such screams...Will I ever know what scars this brings

to your soul? ... What is that new look I see in your eyes? I can see pain,

a certain sadness, and a loss of trust."

A DIFFERENT KIND OF PENIS ENVY

Very often, parents explain their choice of circumcision by appealing to

the concern that their intact sons would be ridiculed by their circumcised

peers in the locker rooms. It is most ironic that, instead of educating our

children about the importance of our unique cultural and individual

identity, we, ourselves, as parents, fall prey to the peer pressure.

Another common factor for the choice of circumcision is the father's

circumcision status. Parents argue that they do not want their child to

feel "different" from his father. This "like-father, like-son" syndrome is

widely applied by all groups in the U.S., including Armenians, and it is

even viewed as family tradition. At other times, it is the older sibling

who has been circumcised, so the younger brother is circumcised, too.

However, is there any necessity that all the males in the household have

similar penises? After all, as some human rights activists say, boys do not

undergo plastic surgery when they are a day old to make their noses look

like those of their fathers. In fact, the National Organization of

Restoring Men offers an opportunity to circumcised fathers to look like

their intact sons. These are non-surgical stretching techniques for

foreskin restoration, which can be partially effective in restoring the

lost sensitivity of the glans by rejuvenation of the keratinized skin.

BAPTIZED AND CIRCUMCISED? CIRCUMCISION ISSUE IN THE HISTORY OF CHRISTIAN

ARMENIANS

For centuries, circumcision has been a crucial issue in the lives of

Armenians. Leaving their children intact was a significant aspect of ethnic

identity and religious association among Christian Armenians. Living under

Islamic domination, the preservation of this identity was continuously at

stake. It is known from history that the Turkish government led systematic

and coercive policies to convert Armenians to Islam. In his book, Turkish

Documentary Sources about Armenians, the historian Avetis Papasian writes

that, after 1464, Armenian boys were forcefully taken away from their

families by the Turkish government. This plan of ethnic cleansing was a

real menace for Armenians living in historic Western Armenia. Every two to

five years, representatives of the Turkish government would gather

physically fit and healthy boys between eight and twenty years of age. Then

they would be transported to Istanbul where Armenian boys were made to

ceremonially take an oath to convert to Islam. These children then were

ritually circumcised and given new Turkish names.

Eventually, these Armenian males would receive military training and were

brought up as fanatic followers of Islam.

The 17th-century historian Arakel Davrizhetsi [of Tabriz] writes in his

History about the heroic deaths of Christian Armenian youth who resisted

conversion to Islam, which was always accompanied with circumcision, and

chose death instead. These youth were venerated as saints among Armenians

of those times.

During my interview with Stepan Topchian, an Armenian author and literary

figure, he voiced his concern about this new cultural phenomenon.

Circumcision status, Dr. Topchian explained, was one of the distinctive

features of our ethnic and religious identity. He stated that it took a lot

for our forefathers to resist any attempts of forceful assimilation. Today,

they would be amazed at how easily we abandon an important tradition

central to our national identity. He calls for Armenians to be more prudent

and responsible in preserving this heritage that has come all this way,

only to be jeopardized for no valid reason.

It is rather disturbing to witness that a few decades of American reality

proved more potent than centuries of threat of coercive assimilation. In

one of his email letters to me, Gary Harryman wrote, "Of all the horrors

that have been visited upon Armenians in the last century, I hope

circumcision was/is not one of them."

From the perspective of our Christian heritage, it is essential to

acknowledge that there is an inherent fundamental conflict in baptizing

and, at the same time, circumcising our sons. Let us remember what Paul

said to his followers:

"In him [Christ] you were also circumcised, in the putting off of the

sinful nature, not with a circumcision done by the hands of men but with

the circumcision done by Christ, having been buried with him in baptism and

raised with him through your faith in the power of God, who raised him from

the dead..." (Col 2:8 & 11-13.)

"Mark my words! I, Paul, tell you that if you let yourselves be

circumcised, Christ will be of no value to you, at all. Again I declare to

every man who lets himself be circumcised that he is obligated to obey the

whole law. You who are trying to be justified by law have been alienated

from Christ; you have fallen away from grace..." (Gal... 5 v. 2-6)

As part of my efforts to raise awareness about our Christian heritage, I

call for our religious leaders of the American-Armenian community to come

forward and bring their authoritative involvement in this most urgent

issue.

JEWS AGAINST CIRCUMCISION

"We are educated and enlightened Jews who realize that the barbaric,

primitive, torturous, and mutilating practice of circumcision has no place

in modern Judaism," reads the homepage site of the organization Jews

Against Circumcision (JAC). Since ancient times, Jews suffered the grim

consequences of circumcision, which claimed the lives of their infant sons.

In fact, Jewish law allowed the families to forgo circumcision of the third

son, if the family had already lost two previous children as a result of

circumcision.

More and more Jewish people are rejecting the controversial ceremony and

are not afraid to question tradition that is in conflict with common sense,

and basic human rights. "I mourned my own circumcision," Dr. Reiss told me

in a most candid interview. Of Jewish heritage, Dr. Reiss never questioned

this tradition until later in life, when he discovered that "any potential

benefits of circumcision are far outweighed by its risks and drawbacks."

"Jewish people are now leaving their sons intact, as they view circumcision

as a part of Jewish law that they can no longer accept," he explains. In

fact, according to Dr. Reiss, there are proportionately more Jews fighting

against circumcision (as compared to their population size in the U.S.)

than non-Jews. He holds that it is not the Jewish but the American culture

and its medical institutions that are promoting the circumcision industry

in the U.S. He states that, among Jews in Europe, South America, and even

in Israel, circumcision is not universal (only 40% of newborn Jewish boys

in Sweden are being circumcised).

HUMAN RIGHTS: THE ULTIMATE ISSUE

The various cultures of the world have practiced religious and secular

rituals that infringed on the bodily autonomy of the individual, including

female circumcision, infibulations (stitching together the labia to prevent

intercourse before marriage), sterilizations, human sacrifice, feet

binding, body piercing, cutting off the fingers as a sign of mourning, and

other mutilations. As average Westerners, we watch National Geographic

films about male and female circumcision rites in Africa and, with our

typical ethnocentrism, label them as "primitive," "unclean," and "brutal."

We assume that what happens in American hospitals is "scientific,"

"sterile," and "humane."

Nonetheless, human rights activists argue that, regardless of the place and

style of the procedure, both male and female circumcisions are genital

mutilations and violations of the child's right to an intact body. "No

one," says Dr. Denniston in his interview, "and especially not a doctor has

the right to remove normal body parts from another individual (mutilation

by definition). Nor do they have the right to torture that individual."

Some parents resent the procedure because it involves genital manipulation

by the circumciser, which they think strips their sons of their innocence.

As Marilyn Milos put it in her interview, "Circumcision is where sex and

violence meet for the first time, and it imprints the connection between

the brain and the penis with pain instead of the pleasure that organ is

meant to feel." Unfortunately, the proponents of circumcision either avoid

or trivialize discussions of such important aspects as psychosexual trauma

associated with routine neonatal circumcision, the degree of pain, and

human rights issue.

The research paper on "Male Circumcision: Pain, Trauma and Psychosexual

Sequelae" (Journal of Health Psychology, May 2002, Boyle, G., Goldman, R.,

Svoboda, S., Fernandez, E.) views circumcision as a procedure that

"involves an imbalance of power between perpetrator and victim, contains

both aggressive and libidinal elements, and threatens a child's sexual

integrity by amputating part of the genitalia." Involuntary neonatal

circumcision is described as an experience of "violence and powerlessness -

inflicted by other human beings."

Many adult men who recognize the importance of the irreplaceable part of

their body that has been removed without their knowledge or consent tend to

manifest feelings of resentment and emotional suffering. As cited by

authors, "avoidance of the topic of circumcision, or obsessive

preoccupation with such a loss" is typical of the circumcised individual.

The article also discusses the so-called "I'm circumcised and I'm fine"

syndrome, which is a common attitude of the circumcised father, "who

unreasonably insists on the circumcision of a son in the face of contrary

evidence."

Dr. Paul Fleiss discusses the psychological mind-set of the circumcised

father and explains how to best overcome these feelings.

"A circumcised father who has mixed feelings about his intact newborn son

may require gentle, compassionate psychological counseling to help him come

to terms with his loss and to overcome his anxieties about normal male

genitalia. In such cases, the mother should steadfastly protect her child,

inviting her husband to share this protective role and helping him diffuse

his negative feelings. Most parents want what is best for their baby. Wise

parents listen to their hearts and trust their instinct to protect their

baby from harm. The experience of the ages has shown that babies thrive

best in a trusting atmosphere of love, gentleness, respect, acceptance,

nurturing, and intimacy. Cutting off a baby's foreskin shatters this

trust."

LEGAL REMEDIES

Today, lawyers and human rights activists raise the issue of limiting the

parental right of consent for this procedure. The American Academy of

Pediatrics clearly states that there is "no absolute medical indication for

routine circumcision." By this reasoning, parental consent for this

surgical operation, which is neither diagnostic nor treating a disease, is

not legitimate. "Circumcision can always be performed in adulthood with

fully informed consent for those individuals who desire it," says Dr.

Zargarian. "I always tell parents, let the child grow up and decide for

himself. Do not assume that he would want to be circumcised and remove a

healthy, functional, and most importantly, a private body part."

Furthermore, the Code of Medical Ethics prohibits a physician from advising

unnecessary medical or surgical treatment. Thus, the practice of

circumcision is de facto in conflict with medical ethics. As Dr. George

Denniston pointed out in his email letter, "Armenians are one of many

minority groups who never before dreamed of removing half the skin from

their son's normal penis, who have been betrayed by the American medical

profession."

David Llewellyn, who is the Director of the Atlanta Circumcision

Information Center as well as a practicing attorney, calls for parents,

whose children have been victims of wrongful circumcision, to enforce legal

rights on behalf of their child. He holds that lawsuit is the only potent

way to stop physicians and institutions from misinforming or soliciting

this unnecessary procedure. (Legal Remedies for Penile Torts, The Compleat

Mother, 1995).

Little do the doctors know that today's helpless infants that they are now

circumcising may grow up to become potential plaintiffs of tomorrow. As the

number of lawsuits arising from circumcision is growing, so is the number

of the states who have ended Medicaid funding of routine neonatal

circumcision. Arizona, Missouri, North Carolina, Montana, Utah, Florida,

and Maine have joined California, Mississippi, Nevada, North Dakota,

Oregon, and Washington in not funding neonatal routine circumcision.

The history of circumcision reveals a chronicle wherein the motives of the

practice have been continuously changing, consistent with the times and the

beliefs of people practicing it. From assign of slavery to a mark of social

prestige, to its "medical" popularity, circumcision has been and remains

one of the most controversial procedures. As members of a society that

places high value on the rights of its citizens, we should question

circumcision regardless of our religious and cultural backgrounds.

Today's society should ultimately be guided by sound science, common sense

and respect for basic human rights. The myths surrounding circumcision are

inconsistent with our values and beliefs. Circumcision is not "clean," it

is not "fashionable" or "prestigious," nor is it medically necessary. If

you believe in evolution, it contradicts evolution. If you believe in God,

than cutting off a part from God's creation is a disbelief. Circumcision

does not belong to Christians, it does not belong to Armenians. It is not

humane, and it is not what our children are asking for. Ultimately,

circumcision is against any parental instinct.

"Circumcision is irreversible," concludes Dr. Zargarian. "I call for

parents to be more considerate and responsible in their decisions!"

Article copyright The Armenian Reporter International.

2005-11-26T16:06:00.000-05:00

SHREWSBURY, N.J. -- In what is believed to be the first time a patient from Connecticut undergoes a rare living-donor nerve transplant, a 21-year-old male from New London received donor nerves from his mother to reverse the paralysis of his right arm on Friday, January 7, 2005. The procedure took place at Monmouth Medical Center, and was performed by a team of medical professionals led by Dr. Andrew Elkwood, M.D. of the Plastic Surgery Center in Shrewsbury, NJ.

The nerve transplant is a complex procedure that utilizes advanced technology in order to reverse many life-altering paralyses. This weekend's surgery was performed on 21-year-old Dylan Brigham's arm, which was left paralyzed from a motorcycle accident in August 2003. As part of the procedure, the medical team surgically removed nerves from his mother's legs, and simultaneously transplanted them into Dylan's arm. The procedure also required the doctors to take nerves from Dylan's own legs and transplant them into his arm.

"Nerve transplants have shown incredible promise in helping once-paralyzed patients regain mobility that surpasses their previous expectations for recovery," said Dr. Andrew Elkwood. "We are extremely pleased with the success of previous living-donor nerve transplants, and anticipate further advancements in medical technology that will continue to help reverse life-altering paralyses caused by accidents, strokes and other medical tragedies."

In May 2004, Dr. Andrew Elkwood performed a father-daughter living-donor nerve transplant, which resulted in the patient gaining full mobility of her once paralyzed arm surpassing all prior prognoses for her recovery. Dr. Elkwood used the same procedure in June 2004 to restore functionality of another patient's paralyzed arm, which was left paralyzed from a car accident nine months prior to the surgery. In addition, Dr. Elkwood made use of cadaverous nerves when he performed the first nerve transplant ever to take place on the East Coast in March 2003, on a patient who was shot in the arm and leg. The patient has since regained near-complete functionality of his once paralyzed arm and leg.

About Dr. Elkwood

Dr. Andrew Elkwood, M.D., is a plastic and reconstructive surgeon who performs unique operations involving nerve rebuilding and complex reconstruction. Dr. Elkwood and his team are among the few doctors in the country to perform operations such as brachial plexus reconstruction, facial reanimation, nerve transplantation, and nerve grafting to preserve erectile function after prostate cancer. Dr. Elkwood is certified by the American Board of Surgery and the American Board of Plastic Surgery in General Surgery and Plastic Surgery. He is also a Fellow of the American College of Surgery (FACS) and a Fellow of the American Society of Aesthetic Plastic Surgery. Dr. Elkwood practices at The Plastic Surgery Center, with offices in NJ and Manhattan. For further information, please visit the Plastic Surgery Center's website at www.looknatural.com.

2005-11-25T03:36:00.000-05:00

Byline: Puneet. Gupta, V. Bhartia

INTRODUCTION: Common Bile Duct stones (CBD) are found in approximately 16% of the patients undergoing Laparoscopic cholecystectomy (LC). Till recently, the gold standard for treating CBD stones was endoscopic removal, if that failed, then open surgery. However, in the laparoscopic era, the best treatment for CBD stones is a matter of debate and it continues to evolve. The objective of the present study is to determine that laparoscopic CBD exploration (LCBDE) is a safe, feasible and single-stage option for the management of CBD stones. MATERIALS AND METHODS: Out of the 2900 laparoscopic cholecystectomies between 1998-2004 we did selective intraoperative cholangiogram in 262 patients who were suspected to have CBD stones based on deranged liver function tests, dilated CBD with or without CBD stone on sonography or having the history of recent jaundice / pancreatitis. If CBD stone was found, either a transcystic or transcholedochal exploration was done depending on the size, site, number of stones and CBD diameter. Choledochotomy was closed over a t-tube in the majority of the patients. Primary closure of CBD was done in few patients and in one patient we placed an antegrade stent and in another we placed endoscopic stent into the CBD laparoscpically which was removed after four weeks. RESULTS: Till date we have performed LCBDE in 64 patients. Transcystic exploration was done in 14 patients and transcholedochal exploration was done in 46 cases out of which 2 patients had minor biliary leak which settled on conservative treatment in 2-3 days. Four patients required conversion to open surgery as there were multiple stones. We did not have any major complication and on 6 months follow-up in 76% patients, none was found to have residual stone. CONCLUSION: The treatment of CBD stones depends on the resources available, technical limitations and the surgeon's expertise. Laparoscopic CBD exploration is a safe, feasible and single-stage option for the management of CBD stones.

INTRODUCTION

Common bile duct (CBD) stones are found in approximately 10-16% of the patients undergoing Laparoscopic cholecystectomy (LC). [1],[2],[3],[4] Until recently it was generally agreed that if stones are detected in CBD preoperatively, it seemed appropriate to remove them prior to LC by Endoscopic Sphincterotomy (ES). If CBD stone could not be extracted by ES, then CBD stone was extracted by open CBD exploration.

However, in the present laparoscopic era, the best treatment for patients with choledocholithiasis is a matter of debate and the management of choledocholithiasis continues to evolve.[5] If the stones are found by intraoperative cholangiography during LC, the surgeon may either do the LC and refer the patient to ES postoperatively, or he may convert to open CBD exploration or in the current times he may do LCBDE.

The advent of ERCP and ES dramatically changed the management of CBD stones. ERCP and ES is a quick and often painless procedure, successful in> 90% of the patients.[6] However, there are a few adverse effects of the procedure like pancreatitis, bleeding, failure to clear duct, cholangitis, recurrent stone formation and possibility of malignancy in the long run.[7] The second revolution in the management of the bile duct stones came with advancement in the laparoscopic surgery.

The objective of the present study is to determine that laparoscopic CBD exploration is a safe, feasible and single-stage option for the management of CBD stones.

MATERIALS AND METHODS

A retrospective analysis was done on the patients undergoing LC between Janaury 1998 - November 2004. We have performed 2900 LCs for symptomatic cholelithiasis in our department. Thorough history and clinical examination was done and the patient was investigated in the form of routine blood tests, liver function test including amylase and abdominal sonography. If there was suspicion of CBD stone, on the basis of predictors of CBD stone as shown in [Table:1], patients were subjected to selective Intraoperative cholangiogram (IOC). We have not used any scoring system for predicting the CBD stone, and did the IOC even if one of the factors was positive.

Patients with choledocholithiasis associated with mild gallstone pancreatitis were operated if the Ranson score was 3 or less. If the Ranson's score was> 3, surgery was postponed till the acute bout of pancreatitis subsided.

Patients who were unfit for operation or those with severe pancreatitis / cholangitis and those who were diagnosed to have CBD stone with bile duct diameter < 6 mm were subjected to ERCP and were excluded from the present study. Patients who had previous upper abdominal surgery or previous ERCP were also excluded from the present study.

Technique The standard 4-port configuration for LC was used. A fifth port was made in between the right midclavicular and epigastric port just below the subcostal margin for inserting the choledochoscope.

The fundus of the gall bladder was retracted towards the right shoulder and the hartmans pouch was retracted downwards and outwards toward the right hip. Dissection began on to the neck of the gall bladder and continued proximally until the junction of gall bladder with the cystic duct was clearly defined. Dissection was continued proximally on to the cystic duct until there was adequate length to perform cholangiogram. Then the cystic duct was milked towards the gall bladder to dislodge any cystic duct stone into the gall bladder. A clip was applied on the gall bladder side to prevent any back slippage of gallstone into the CBD and to prevent biliary spillage into the operative field.

IOC was done using a ureteric catheter (4-5 Fr) or an infant feeding tube (no 5-6), which was passed through the cystic duct (after making a small nick in the cystic duct) into the CBD. After the insertion of the catheter, a clip was applied snugly to prevent any back leakage of the contrast medium. Digital C-arm fluoroscopy provided the real time imaging of the biliary tree. In cases where the cystic duct could not be cannulated, contrast was directly injected into the CBD through a lumbar puncture needle (Fr 24) percutaneuosly.

On cholangiogram, we looked for any filling defect- it's size, site, number of bile duct stones, and free passage of contrast into the duodenum and for any anatomical variation of the biliary tree. We selected transcystic or transcholedochal approach to remove CBD stones depending on the factors shown in [Table:2].

CBD stone were extracted with the help of Dormia basket / balloon catheter, irrigation/suctioning or by simply manipulating bile duct using blunt forceps. After retrieving the stones, the cystic duct stump was closed with clips or suture ligature and the gall bladder was removed in the usual manner.

Transcholedochal exploration was performed in the following manner. After opening up of the Calot's triangle, the anterior surface of the CBD was dissected carefully and choledochotomy was performed by a longitudinal incision with the help of endoscopic knife just below the insertion of the cystic duct into the bile duct. In the initial few cases we used stay suture before performing choledochotomy but later we incised bile duct longitudinally without any stay sutures. The stones were retrieved by spontaneous evacuation while incising the bile duct, blunt instrumental pressure with atraumatic forceps, Dormia basket, Fogarty balloon catheter or irrigation and suction.

Completion cholangiography or choledochoscopy was performed to assess the completeness of the procedure. For the initial few case, we did not have the choledochoscope, so we used 5.5 Fr bronchoscope for the purpose. In the later part we performed cholagiosciopy with the help of Choledochoscope (Fr 3.8, Olympus).

Choledochotomy was closed over a t-tube with continuous 3'0 vicryl suture. We did primary closure of CBD in a few cases after assessing the clearance of the CBD and in one case we placed a trancystic antegrade stent (using 5Fr ureteric catheter) which was brought out via cystic duct. The cystic duct was ligated twice with the antegrade stent in situ using 2'0 vicryl. In another case we placed a modified endobiliary stent (commercially available endobiliary stent, Fr 7 and 9 cm in length, with elimination of the proximal flap on the biliary side) into the distal CBD with distal flange through the papilla into the duodenum with the aid of choledochoscope.

After bile duct closure, cholecystectomy was performed in the usual manner. We placed an infrahepatic tube drain in all the cases which was usually removed on Day 3-4 as the output decreased below 30 ml/day.

RESULTS

Out of the 2900 patients undergoing LC, 262(9%) patients were subjected to selective IOC due to the suspicion of CBD stone based on the predictors of CBD stone as given in [Table:1].[8] Out of the 262 patients, 182 patients were female and 80 were male. The mean age group of the patient was 42 years (10-88 years).

Out of the 262 patients undergoing IOC, CBD stones were detected in 64 cases (24%). Out of 64 cases, 25 cases had a preoperative diagnosis of CBD stone (USG) and the rest were picked up on IOC. We removed CBD stones transcystically or by choledochotomy as shown in [Table:3].

Median duration of the procedure was 75 min (60-150 min). At the beginning of our experience the duration was longer, particularly in patients undergoing choledochotomy after failed transcystic extraction. The time taken for choledochotomy was 30-40 min more than that for the transcystic approach.

Post-operative course was similar to that of LC in the patients where transcystic exploration was done and the patient was discharged on post-operative Day (POD)3.

In patients who had undergone transcholedochal approach, t-tube was clamped on POD 4 and was removed on POD 7 without routine t-tube cholangiogram. Intra-abdominal drain was removed as the patients started oral diet and the drain output < 30 ml/day. All the patients were discharged on POD 7 except 2 patients who had minor biliary leak which settled on conservative management in 2-3 days.

In patients where we put antegrade stent, we removed the stent on POD 4 and the patient was discharged on Day 5.

We placed modified endobiliary stent laparoscopically into the CBD across the duodenum in one patient and the stent was removed after 4 weeks by endoscopy.

We did not have any mortality and the various complications which we encountered during laparoscopic CBD exploration are shown in [Table:4].

We had to convert the laparoscopic procedure to conventional open CBD exploration in 4 patients. Out of these, we could not clear the bile duct in 3 patients due to multiple stone and in 1 patient there were severe adhesions present in the Calot's triangle and the bile duct could not visualized properly. In 2 patients we had minor bile leak after removal of t-tube which settled on conservative treatment in 2-3 days. Minor wound infection in the form of erythema and serous collection at the port site occurred in 2 patients and 1patient had small hematoma at the epigastric port site through which gall bladder was extracted conservatively. Mild pancreatitis developed in 2 patients which resolved on conservative treatment in 2-3 days.

Follow-up after 6 months were completed in 49 patients (76%) and no missed / residual stone was found. Rest of the patients were lost to follow-up.

DISCUSSION

The best treatment of choledocholithiasis must be simple, reliable, readily available, cost-effective and patient-friendly. The incidence of CBD stones in patients undergoing LC is 10-16%, so the surgeon must be prepared to manage CBD stones appropriately, depending on whether the diagnosis is made preoperatively or during the surgery.[10] If choledocholithiasis is suspected preoperatively, recommendations in past were to get an ERCP and if stones were found, ES and extraction of stones.

But there are a few important variables to consider before committing ourselves to this so-called old testimony. Firstly, ES is successful in> 90% of the patients but it is highly dependent on the availability of an experienced endoscopist to achieve such a high success rate.[11] The second consideration is that of cost and the need for a second stage procedure.[12],[13] If a stent is placed then removal needs another endoscopy, usually after 4 weeks. The intervening period requires antibiotics in many cases which further increases the cost factor. Thirdly, there are no selective criteria that can accurately predict the presence of CBD stone.[14] Taking into account all the positive predictors (history, clinical, biochemical, and sonography) for CBD stone, in most of the series reported in the literature, positive ERCP occurs in only up to 30-35% of the cases.[15] On the other hand if we do routine IOC, we detect the stone in about 10% of cases and on selective IOC, CBD stones can be detected in about 25% of the cases.[16]

Finally, the risk of potential complications of ERCP and ES should be considered. Although the complication rate is decreasing with increasing experience, pancreatitis continues to be a problem in most of the reported series, with an incidence of morbidity up to 7% and mortality of 0.2-2.3%.[17] The Sphincter of Oddi (SOD) provides a barrier that prevents duodeno-biliary reflux and this function is permanently lost after sphincterotomy.[18] ES increases duodenal reflux and a higher rate of bactibilia (60%) with the increasing rate of recurrent biliary stone formation.[19]

This duodeno-biliary reflux further causes biliary epithelium to adapt to a new environment. Chronic bactibilia, in addition to pancreatic reflux (which is proved to be responsible for higher rates of malignancy in case of congenital choledochal cyst) may lead to neoplastic changes in the biliary epithelium.[20],[21]

LCBDE has considerable advantages for treating both gall bladder and bile duct stones in a single stage without any preoperative examination to detect the presence of stones in CBD.[22],[23] The main drawback of LCBDE is the increased operative time and the cost involved, particularly with the use of choledochoscope. There is a possibility of false positive cholangiogram as in open procedure but did not encounter this problem. LCBDE is successful in 75-95% of the patients and is comparable to the endoscopic treatment. Moreover if the endoscopic treatment fails, particularly in the postoperative setting, this may require a third stage open procedure. While if LCBDE fails, one can convert at the same time. Also as the experience is increasing in LCBDE, the success rate will further improve. Liebermann et al and Martin et al found that that the single stage procedure had significant lower morbidity and shorter hospital stay resulting in lower cost than those of staged ES and LC.[24],[25]

In our study, patients who were unfit for operation or those with severe pancreatitis / cholangitis or with previous upper abdominal surgery or previous ERCP or with CBD stone but bile duct dilatation < 6 mm were subjected to ERCP and were excluded from the present study. We have deliberately not done ERCP in the study group patients considering the cost, two-stage procedure, risk of complications and the possibility of failure. Our Institute being a centre for training in laparoscopic surgery also gave us the impetus to utilize LCBDE.

Certainly, ERCP has been an important modality for treating leftover CBD stone after LC. The current trend is to utilize ERCP less, preoperatively, while expanding its role in the postoperative setting.

Various randomised controlled studies comparing the two-stage (ERCP with LC) procedure and one-stage LC with LCBDE showed that the one-stage procedure resulted in a shorter stay and similar stone clearance rates.[26],[27] Various complications of LCBDE reported in the literature are summarized in [Table:5].[23]

Transcystic CBD exploration is preferred as it is easy, more physiological, associated with less complication, does not require t-tube placement and intra-corporeal suturing and the post-operative course is almost similar to patients undergoing LC alone. However, a transcholedochal approach is a must if there are-multiple stone (>5), stone> 6 mm, proximal stone, CBD size < 6 mm, cystic duct size < 4 mm (too narrow to pass choledochoscope), and if there is any anatomical variation of the biliary tree.

Traditionally, CBD exploration is accompanied by t-tube drainage of CBD. Nevertheless, there are a few disadvantages -inconvenience and discomfort, delayed recovery, longer stay, risk of tube displacement, risk of infection and rarely, fracture of tube fragment retention in the CBD.[28]

Lange et al first reported laparoscopic CBD primary closure with antegrade stent.[29] Recently, many studies have shown feasibility and potential advantages of antegrade stent which include decompression of CBD postoperatively, facilitation of ERCP cannulation postoperatively and early return to full activity.[30]

Nowadays the combined laparo-endoscopic approach to CBD stone is talked about in which a modified plastic biliary stent is used (modified by breaking the proximal flange).[8] Potential problems with the plastic stent are bile leak, stent occulusion, early stent migration and the need of future endoscopy for the removal of the stent.[31],[32]

In our study of 2900 patients undergoing LC, we performed IOC in 262 patients based on our selection criteria. Out of 262 patients we found CBD stones in 64 patients. We were able to successfully remove stones in 60 patients and in 4 patients, we had to convert to open CBD exploration as we were not able to remove completely all the stones laparoscopically.

Now we have every confidence in the technique of LCBDE, our success rate is 93% (4 conversions out of 64 explorations), there was no major complication, and in follow-up, no residual stone was found. Our operating time is also decreasing as all the team members are getting familiarised with the technique and equipments. Although we still rely on ERCP and ES for high-risk patients or those who are unfit for operation or those with severe pancreatitis / cholangitis or those who are diagnosed CBD stone with bile duct diameter < 6 mm.

Our results are similar to the published data in the literature in terms of stone clearance, minimal complication, a shorter hospital stay, and rapid recovery time.[33],[34] The optimal management of choledocholithiasis remains unclear in the present laparoscopic era. Management at a single stage is the optimal approach in terms of safety, patient satisfaction and cost-effectiveness.

CONCLUSION

CBD stones are associated with about 10-16% of the patients undergoing cholecystectomy. Treatment algorithms have changed for CBD stones with the advent of endoscopic management which is now getting further modified with the advancement in laparoscopic surgery. The treatment of CBD stones depends on the resources available, technical limitations and the surgeon's expertise. Laparoscopic CBD exploration is a safe, feasible and single-stage option for the management of CBD stones.

References

1. Curet MJ, Pitcher DE, Maritn DT, Zucker KA. Laparoscopic antegrade sphincterotomy: A new technique for the management of complex choledocholithiasisis. Ann Surg 1995;221:149-55.

2. Southern Surgeon's Club: A prospective analysis of 1518 Laparoscopic cholecystectomies. N Engl J Med 1997;324:1073-8.

3. Petelin JB. Laparoscopic Common Bile Duct Exploration. In: Zucker KA. Surgical Laparoscopy 2nd Ed. Lippincott: Williams and Wilkins; 2001. p. 809-16.

4. Giordano L, Phillips EH. Laparoscopic Common Bile Duct Exploration. In: Soper NJ, Swanstorm LL, Eubanks WS. Mastery of Endoscopic and Laparoscopic Surgery 2nd Ed. Lippincott: Williams and Wilkins; 2005. p. 319-32.

5. Tokumara H, Umezawa A, Cao H, Sakamoto N, Imoaka Y, Oucchi A, et al . Laparoscopic management of CBD stones: Transcystic approach and choledohotomy. J Hepatobiliary Pancreatic Surg 2002;9:206-12.

6. Perissat J, Collet DR, Belliard R. Gallstone: Laparoscopic treatment, intraoperative lithotripsy followed by cholecystostomy or cholecystectomy. Endoscopy 1989;21:373-4.

7. Thomson MH, Tranter SE. All comers policy for laparoscopic exploration of the bile duct. BJS 2002;89:1608-12.

8. Soltan HM, Kew L, Toouli J. A simple Scoring system for predicting bile duct stones in patients with choledocholithisis. J Gastrointest Surg 2001;5:434-7.

9. Wagner AJ, Traverso WL. Laparoscopic Common bile duct exploration. In: Cameron J - Current Surgical Therapy, 8th Ed. Baltimore: Elsevier Mosby; 2004. p. 1199-203.

10. Kim EK, Lee SK. Laparoscopic treatment of choledocholithiasis using modified biliary stents. Surg Endo 2004;18:303-6.

11. Freeman ML, Nelson DB, Sherman S, Haber GB, Herman ME, Dorsher PJ, et al . Complication of endoscopic billiary sphincterotomy. N Engl J Med 1996;335:909-18.

12. Bergman JJGHM, Rouws EAJ, Fockenc P, Van Berkel Am, Bossuyt PM, Tijssen JG, et al . Randomised trial of endoscopic balloon dilation Vs endoscopic sphincterotomy for rem of CBD stone. Lancet 1997;349:1124-9.

13. Urbach DR, Khajanchee YS, Jobe BA, Standage BA, Hansen PD, Swanstorm LL. Cost effective management of CBD stones- a decision analysis of the use of ERCP, intraopearative cholangiogram and laparoscopic CBD exploration. Surg Endo 2001;15:4-13.

14. Decker G, Borie F, Millat B, Berthou JC, Deleuze A, Drouard F, et al . One hundred laparoscopic choledochotomies with primary closure of the CBD. Surg Endo 2003;17:12-8.

15. Petelin JB. Laparoscopic Common Bile Duct exploration. Surg Endo 2003;17:1705-15.

16. Berci G, Morgensern L. Laparoscopic management of CBD stones: A multi-institutional SAGES study. Surg Endo 1994;8:1168-75.

17. Tranter Se, Thompson MH. Comparison of endoscopic sphicterotomy and laparoscopic exploration of CBD. BJS 2002;89:1495-504.

18. Bergman JJGHM, Van Berkel AM, Groen AK, Schoeman MN, Offerhaus J, Tytgat GN, et al . Biliary manometry, bacterial characterstics, bile composition and histologic changes fifteen to seveteen yr after ES. Gastrointest Endosc 1997;45:400-5.

19. Sand J, Airo I, Hiltrunen KM, et al . Changes in biliary bacteria after endoscopic cholangiography and sphincterotomy. Am Surg 1992;58:324-8.

20. Tanaka M, Takahta S, Konomi H, Matsunage H, Yokohata K, Takeda T, et al . Long term consequences of endosphincterotomy for the Bile duct stones. Gastointest Endosc 1998;48:465-9.

21. Ekbom A, Hsieh C, Yuen J, Trichopoulos D, Mclaughlin JK, Lan SJ, et al . Risk of extrahepatic bile duct cancer after cholecystectomy. Lancet 1993;342:1262-5.

22. Cushiery A, Lezoche E, Morino E, Crace E, Lacy A, Toouli J, etal. EAES multicentre prospective randomised trail comparing two stage Vs single stage management of patients with gallstones and choldocholithiasis. Surg Endo 1999;13:952-9.

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24. Leibermann MA, Philips EH, Carroll BJ, Fallas MJ, Rosenthal R, Hiatt J. Cost effective management of complicated choledocholithiasis: Laparoscopic transcystic exploration Vs ES. J Am Coll Surg 1996;182:488-94.

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2005-11-23T20:12:00.000-05:00

Tucson, Ariz. -- A deep, elongated superficial muscular aponeurotic system (SMAS) flap with a novel inverted L-shape design produces significant cheek elevation besides reducing sagging in the lower face and neck, according to Robert M. Dryden, M.D., F.A.C.S. and Craig Davis, D.D.S., M.D.

Instead of initiating the apex of the SMAS flap at the traditional point 1 cm below the zygomatic arch, or cheekbone, Drs. Dryden and Davis start the apex 1 cm superior to the zygomatic arch.

A solid understanding of SMAS anatomy underlies the new approach, designed by Dr. Dryden. As a layer of fibrous and muscle tissue located deep to the skin, the SMAS, which is used like a handle to move the fatty tissue of the face, is more substantial above the zygomatic arch than in the midface, says Dr. Davis, a cosmetic surgery fellow of Dr. Dryden's at Arizona Centre Plastic Surgery, Tucson, Ariz.

The connective tissues of the SMAS in the temple area fuse before reaching and entering the zygomatic arch. In the midface however, the SMAS is thinner, composed of wisps of connective tissue. Lengthening the SMAS flap by initiating it in a higher position incorporates the weaker midfacial SMAS into the body of the flap, which the surgeons then suspend over the zygoma. Attaching the suspension and fixation sutures here lodges them in one of the sturdiest areas of the SMAS.

Placing the apex of the SMAS flap above the zygoma instead of below it takes advantage of these anatomic features. The higher flap attachment produces the marked cheek elevation that characterizes this technique.

The SMAS can be brought forward and attached by either plication or imbrication. Plication involves folding the overlapping portion of the SMAS in on itself and fixing it with buried suspension sutures. The imbrication technique removes the SMAS overlap and uses buried suspension sutures to fix the remaining edges. Plication is thought to offer less chance of facial nerve branch injury, but according to Dr. Dryden, "imbrication results in cleaner contours and a more natural appearance, since there's no underlying excess tissue left to bunch up under the skin."

The risk of facial nerve damage increases with imbrication and the dissection of tissues in a deeper plane, but Drs. Davis and Dryden reduce the risk by dissecting the SMAS flap with a monopolar cutting current that passes through a Colorado needle.

"As the dissection plane nears these fibers, an electric current stimulates twitching of nearby innervated muscles. By carefully observing the operative field and juxtaposed tissues, we're warned of impending danger to vital structures," Dr. Dryden says.

The sharp tungsten tip of the needle allows the surgeons to use very low wattages, substantially reducing bleeding and minimizing tissue damage. They can then extend the SMAS flap over the zygomatic arch and into the temporal area despite the density of facial nerve fibers there.

Patients receive sedation or general anesthesia. The surgeons make standard rhytidectomy skin incisions around the ear after injecting local anesthesia and infusing tumescent solution. After initiating the skin flap 1 cm above the zygomatic arch, they elevate it, extending it anteriorly for 2 to 3 cm and inferiorly 2 to 3 cm beneath the mandible-- making it 1 to 2 mm thick.

"The flap should be as thin as possible, staying superficial to the seventh nerve fibers," Dr. Dryden says.

After lifting the flap up and back, about 1 cm of SMAS can usually be overlapped and removed superiorly at the posterior base. Closing sutures are directed up and back to enhance cheek lift.

The technique has been used on approximately 100 patients treated from 2002 through the present, and frequently combined with brow elevation, blepharoplasty, chin augmentation or laser resurfacing. Patient ages ranged from 26 to 85.

The cheek elevation, positioned higher than in traditional facelifts or mini-facelifts, decreases the nasolabial fold and its underlying crease. These results have been variable but present in all patients, Dr. Dryden says.

Complications were minimal, with no incidences of hematoma, motor nerve palsy, skin flap necrosis, infection, or SMAS flap fatigue. Two or three patients had transient seventh nerve palsies that resolved postoperatively.

"The inventive design of this SMAS flap produces superior cheek elevation, and it's a safe and effective way to rejuvenate the lower two thirds of the face" Dr. Dryden says. CST

For more information: Campiglio, GL, Candiani P. Anatomical study on the temporal fascial layers and their relationship with the facial nerve. Aesth Plast Surg. 1997:21;69-74