Background In 2006, we reported results of a randomized trial of laparoscopic paraesophageal hernia repair (LPEHR), comparing primary diaphragm repair (PR) with primary repair buttressed with a ...biologic prosthesis (small intestinal submucosa SIS). The primary endpoint, radiologic hiatal hernia (HH) recurrence, was higher with PR (24%) than with SIS buttressed repair (9%) after 6 months. The second phase of this trial was designed to determine the long-term durability of biologic mesh-buttressed repair. Methods We systematically searched for the 108 patients in phase I of this study to assess current clinical symptoms, quality of life (QOL) and determine ongoing durability of the repair by obtaining a follow-up upper gastrointestinal series (UGI) read by 2 radiologists blinded to treatment received. HH recurrence was defined as the greatest measured vertical height of stomach being at least 2 cm above the diaphragm. Results At median follow-up of 58 months (range 42 to 78 mo), 10 patients had died, 26 patients were not found, 72 completed clinical follow-up (PR, n = 39; SIS, n = 33), and 60 repeated a UGI (PR, n = 34; SIS, n = 26). There were 20 patients (59%) with recurrent HH in the PR group and 14 patients (54%) with recurrent HH in the SIS group (p = 0.7). There was no statistically significant difference in relevant symptoms or QOL between patients undergoing PR and SIS buttressed repair. There were no strictures, erosions, dysphagia, or other complications related to the use of SIS mesh. Conclusions LPEHR results in long and durable relief of symptoms and improvement in QOL with PR or SIS. There does not appear to be a higher rate of complications or side effects with biologic mesh, but its benefit in reducing HH recurrence diminishes at long-term follow-up (more than 5 years postoperatively) or earlier.
Background Gastroesophageal reflux disease (GERD) is a very prevalent disorder. Medical therapy improves symptoms in some but not all patients. Antireflux surgery is an excellent option for patients ...with persistent symptoms such as regurgitation, as well as for those with complete symptomatic resolution on acid-suppressive therapy. However, proper patient selection is critical to achieve excellent outcomes. Study Design A panel of experts was assembled to review data and personal experience with regard to appropriate preoperative evaluation for antireflux surgery and to construct an evidence and experience-based consensus that has practical application. Results The presence of reflux symptoms alone is not sufficient to support a diagnosis of GERD before antireflux surgery. Esophageal objective testing is required to physiologically and anatomically evaluate the presence and severity of GERD in all patients being considered for surgical intervention. It is critical to document the presence of abnormal distal esophageal acid exposure, especially when antireflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and workup of GERD, and no single test alone can provide the entire clinical picture. Results of testing are combined to document the presence and extent of the disease and assist in planning the operative approach. Conclusions Currently, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery. Additional studies with long-term follow-up are required to evaluate the diagnostic and therapeutic benefit of new technologies, such as oropharyngeal pH testing, multichannel intraluminal impedance, and hypopharyngeal multichannel intraluminal impedance, in the context of patient selection for antireflux surgery.
Background Peroral endoscopic myotomy (POEM) has recently been described in humans as a treatment for achalasia. This concept has evolved from developments in natural orifice translumenal endoscopic ...surgery (NOTES) and has the potential to become an important therapeutic option. We describe our approach as well as our initial clinical experience as part of an ongoing study treating achalasia patients with POEM. Study Design Five patients (mean age 64 ± 11 years) with esophageal motility disorders were enrolled in an IRB-approved study and underwent POEM. This completely endoscopic procedure involved a midesophageal mucosal incision, a submucosal tunnel onto the gastric cardia, and selective division of the circular and sling fibers at the lower esophageal sphincter. The mucosal entry was closed by conventional hemostatic clips. All patients had postoperative esophagograms before discharge and initial clinical follow-up 2 weeks postoperatively. Results All (5 of 5) patients successfully underwent POEM treatment, and the myotomy had a median length of 7 cm (range 6 to 12 cm). After the procedure, smooth passage of the endoscope through the gastroesophageal junction was observed in all patients. Operative time ranged from 120 to 240 minutes. No leaks were detected in the swallow studies and mean length of stay was 1.2 ± 0.4 days. No clinical complications were observed, and at the initial follow-up, all patients reported dysphagia relief without reflux symptoms. Conclusions Our initial experience with the POEM procedure demonstrates its operative safety, and early clinical results have shown good results. Although further evaluation and long-term data are mandatory, POEM could become the treatment of choice for symptomatic achalasia.
Background Single-site laparoscopy (SSL) attempts to further reduce the surgical impact of minimally invasive surgery. However, crossed instruments and the proximity of the endoscope to the operating ...instruments placed through one single site leads to inevitable instrument or trocar collision. We hypothesized that a novel, single-port, triangulating surgical platform (SPSP) might enhance performance by improving bimanual coordination and decreasing the surgeon's mental workload. Study Design Fourteen participants, proficient in basic laparoscopic skills, were tested on their ability to perform a validated intracorporeal suturing task by either an SSL approach with crossed articulated instruments or a novel SPSP, providing true-right and true-left manipulation. Standard laparoscopic (SL) access served as control. Sutures were evaluated using validated scoring methods and the National Aeronautics and Space Administration Task Load Index was used to rate mental workload. Results All participants proficiently performed intracorporeal knots by SL (mean score 99.0; 95% CI 97.0 to 100.9). Performance decreased significantly (more than 50%, p < 0.001) with the SSL approach using 1 rigid and 1 articulating instrument in a cross-wise manner (mean score 39.2; 95% CI 28.3 to 50.1). The use of the SPSP significantly enhanced bimanual coordination (mean score 67.6; 95% CI 61.3 to 73.9; p < 0.001). Participants recorded lower mental workload when using true-right and true-left manipulation. Conclusions This study objectively assessed SSL performance and current attempts for instrumentation improvement in single-site access. While SSL significantly impairs basic laparoscopic skills, surgical platforms providing true-left and true-right maneuvering of instruments appear to be more intuitive and address some of the current challenges of SSL that may otherwise limit its widespread acceptance.
Background Barrett esophagus (BE) caused by gastroesophageal reflux disease can lead to esophageal cancer. The success of endoscopic treatments with BE eradication depends on esophageal anatomy and ...post-treatment acid exposure. Study Design Between January 2008 and December 2009, 10 patients were selected for combination treatment of BE using laparoscopic anti-reflux surgery and endoscopic radiofrequency ablation. Retrospective review of preoperative, procedural, and postoperative data was performed. Results Seven study patients had a pathologic diagnosis of nondysplastic BE and 3 patients had a diagnosis of low-grade dysplasia. Average length of BE lesions was 6.4 ± 4.8 cm. Procedure time averaged 154.4 ± 46.4 minutes. At the time of surgery, the mean number of ablations performed was 4.39 ± 1.99. Six patients were noted to have major hiatal hernias requiring reduction. Five patients (80%) had 100% resolution of their BE at their first postoperative endoscopy. The remaining 3 patients had a ≥50% resolution and underwent subsequent endoscopic ablation. Symptomatic results revealed that 4 patients had substantial dysphagia to solids and other symptoms were minimal. Two patients were noted to have complications related to the ablative treatments. One stricture and 1 perforation were observed. Conclusions Endoscopic radiofrequency ablation of BE at the time of laparoscopic fundoplication is feasible and can effectively treat BE lesions. A single combined treatment can result in fewer overall procedures performed to obtain BE eradication.
Background Natural orifice endoscopic full-thickness colon resection attempts to overcome the need for invasive surgery in selected colorectal indications. Because basic technical requirements have ...not been met so far, the aim of this study was to develop a novel technique for endolumenal colon-wedge resection addressing current shortcomings. Study Design Endoscopic full-thickness colon resection was attempted in a human cadaver model (n = 2), explanted porcine colon stumps (n = 10), and 3 acute pig models. A hypothesized colon lesion was created and retracted into an endoscopic clip closure system (ECCS). Initially used endoscopic graspers (n = 2) were replaced by a T-tag suture approach for retraction (n = 13). T-type anchors were deployed circumferentially to the lesion, which simultaneously marked resection margins. The clip was then applied for pre-resection tissue closure. The inverted tissue was excised by snare resection and was removed together with the sutures. Air leak-pressure of tissue closure was tested. Results Endoscopic full-thickness colon resection was achieved in 14 of 15 attempts. The mean diameter (±SD) of resected animal specimen, including the predetermined margins, was 26 ± 4 mm. Using the T-tag sutures for retraction, the defined lesion was neither touched by an endoscopic grasper nor compromised by puncturing the center. Leak pressure tests revealed a significantly higher air pressure resistance of the pre-resection ECCS closure (61 ± 5 mmHg) compared with the hand-sewn control (26 ± 7 mmHg). Conclusions A novel endoscopic technique for full-thickness colon wall resection using tissue anchors for traction and an ECCS for pre-resection tissue closure appears to address several fundamental surgical principles. However, further studies are necessary before initial clinical application.
Reply Oelschlager, Brant K., MD, FACS; Pellegrini, Carlos A., MD, FACS; Mitsumori, Lee M., MD ...
Journal of the American College of Surgeons,
2012, Letnik:
215, Številka:
1
Journal Article
Background Gastrogastric fistulas (GGFs) are seen in 1.5% to 12.5% of patients after Roux-en-Y gastric bypass (RYGB) bariatric surgery, often leading to failure to lose adequate weight. Objective The ...aim of this study was to assess the feasibility, safety, and percentage of successful primary endoluminal closures of GGFs by using a recently developed tissue apposition system in combination with local mucosectomy. Design A feasibility and outcome study following institutional review board protocol. Setting Tertiary referral teaching hospital, Legacy Health System, Portland, Oregon. Interventions A combination of mucosectomy and nonresorbable tissue apposition is used to achieve a permanent closure of the GGF. Patients Four patients with 5 GGFs after RYGB; the mean fistula diameter of was 18.6 mm (range 10-30 mm). Results Primary closure rate (1 endoscopic session) of 5 GGFs was 100%. The mean procedure time was 88.5 minutes. One to 4 pairs of tissue anchors were used to close the fistulas. The mean time for performing mucosectomy was 21.6 minutes (range 8-42 minutes) and 39.6 minutes (range 12-58 minutes) for fistula closure. Estimated blood loss was on average 2 mL (range 0-5 mL). No complications were recorded. Early success (3 months), as evidenced by early satiety and weight loss, was noted for 3 of 4 patients. After 3 months, only the smallest fistula (10 mm) was still completely closed, and after 6 months, it also showed a pinhole opening. Conclusion It was feasible to close all fistulas endoscopically without complications. Permanent closure of GGFs could not be achieved.
Natural orifice translumenal endoscopic surgery (NOTES) is an emerging field within gastroenterology and gastrointestinal surgery, in which the surgeon accesses the peritoneal cavity through a hollow ...viscus and performs a diagnostic or therapeutic intervention. Introduction of this new field of endolumenal surgery has proceeded in a slow and careful manner. The most common NOTES procedure currently performed worldwide is a transvaginal cholecystectomy. Because of the concerns over bacterial contamination, transanal and transcolonic NOTES procedures are rarely performed. Current research in transanal NOTES procedures are coming to fruition, with hybrid NOTES colorectal resections now in early clinical investigations.
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