Transnasal small-caliber esophagogastroduodenoscopy for preoperative evaluation of the high-risk morbidly obese patient.

BACKGROUND: Esophagogastroduodenoscopy (EGD) is an important facet of the preoperative evaluation for bariatric surgery. Morbidly obese patients are at high risk for airway complications during this procedure, and an attractive alternative is transnasal EGD. This report describes a series of patients evaluated successfully using this technique. METHODS: All patients undergoing preoperative transnasal small-caliber EGD for morbid obesity surgery between September 2004 and June 2005 at a Veterans Affairs Hospital were included in the analysis. The variables assessed were the adequacy of the examination, patient tolerance, the need for sedation, and the ability to perform interventions. RESULTS: The study enrolled 25 patients (17 men and 8 women) with an average age of 55 years (range, 44-63 years) and an average body mass index (BMI) of 47 kg/m2 (range, 38-69 kg/m2). All the patients met the 1991 National Institutes of Health (NIH) Consensus Conference Criteria for bariatric surgery and were undergoing preoperative evaluation. The most common comorbidities were hypertension (82%), diabetes mellitus (80%), and obstructive sleep apnea (68%). All 25 patients had successful cannulation of the duodenum's second portion with excellent tolerance. There were no sedation requirements for 23 (92%) of the 25 patients. Significant pathology was found in 14 (56%) of the 25 patients, including hiatal hernia (28%), gastritis (16%), esophageal intestinal metaplasia (16%), esophagitis (12%), gastric polyps (8%), gastric ulcer (4%) and esophageal varices (4%). Biopsies were indicated for 12 patients and successful for all 12 (100%). CONCLUSION: Transnasal small-caliber EGD is a feasible and safe alternative to conventional EGD for the preoperative evaluation of patients undergoing bariatric surgery. It requires minimal to no sedation in a population at high risk for complications in this setting. In addition, this technique is effective in identifying pathology that requires preoperative treatment and offers a complete examination with biopsy capabilities. This technique should be considered for all morbidly obese patients at high risk for airway compromise during EGD.

The impact of preoperative weight loss in patients undergoing laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a widely performed bariatric operation. Preoperative factors that predict successful outcomes are currently being studied. The goal of this study was to determine if preoperative weight loss was associated with positive outcomes in patients undergoing LRYGBP. METHODS: A retrospective analysis was performed of all patients undergoing LRYGBP at our institution between July 2002 (when a policy of preoperative weight loss was instituted) and August 2003. Outcome measures evaluated at 1 year postoperatively included percent excess weight loss (EWL) and correction of co-morbidities. Statistical analysis was performed by multiple linear regression. P<0.05 was considered significant. RESULTS: The study included 90 subjects. Initial BMI ranged from 35.4 to 63.1 (mean 48.1). Preoperative weight loss ranged from 0 to 23.8% (mean 7.25). At 12 months, postoperative EWL ranged from 40.4% to 110.9 % (mean 74.4%). Preoperative loss of 1% of initial weight correlated with an increase of 1.8% of postoperative EWL at 1 year. In addition, initial BMI correlated negatively with EWL, so that an increase of 1 unit of BMI correlated with a decrease of 1.34% of EWL. Finally, preoperative weight loss of >5% correlated significantly with shorter operative times by 36 minutes. Preoperative weight loss did not correlate with postoperative complications or correction of co-morbidities. CONCLUSIONS: Preoperative weight loss resulted in higher postoperative weight loss at 1 year and in shorter operative times with LRYGBP. No differences in correction of co-morbidities or complication rates were found with preoperative weight loss in this study. Preoperative weight loss should be encouraged in patients undergoing bariatric surgery.

Nitrous oxide and laparoscopic bariatric surgery.

BACKGROUND: Nitrous oxide (N2O) is frequently used to supplement more potent anesthetic agents. One side-effect of N2O is its ability to expand an air-containing space. We investigated if N2O adversely affected operating conditions by distending normal bowel during laparoscopic bariatric procedures. METHODS: 50 morbidly obese patients were divided into 2 study groups. Group 1 patients were ventilated with a halogenated anesthetic/oxygen/air mixture, while Group 2 received a halogenated anesthetic/oxygen/N2O mixture. At 30, 60, and 90 min intervals during the operation, the surgeon was asked if N2O was being used. RESULTS: The surgeons responded correctly only 42% (30 min), 50% (60 min), and 48% (90 min) of the time. In Group 2 (N2O) patients, they incorrectly answered that N2O was not being used 88% (30 min), 68% (60 min), and 68% (90 min); and in Group 1 (air) patients, they incorrectly answered that N2O was being used 28% (30 min), 32% (60 min), and 36% (90 min) of the time. CONCLUSION: We found that using N2O did not cause noticeable bowel distention during laparoscopic bariatric procedures of relatively short duration.

Laparoscopic cholecystectomy.

BACKGROUND: This study was undertaken to determine if patients undergoing laparoscopic cholecystectomy may be discharged home 4 h postoperatively with similar outcomes as patients admitted overnight. METHODS: Patients were randomized to an outpatient group (OP), consisting of patients who were discharged after a 4-h stay in the Post Anesthesia Care Unit (PACU), or to an inpatient group. Variables compared between the two groups included patient demographics; degree of postoperative pain, nausea, vomiting, and patient satisfaction; amount of pain and nausea medication taken; and number of phone calls, readmissions, or complications. Statistical analysis was performed with students t-test, Fisher's exact test, and Wilcoxon's signed rank and rank sums tests as appropriate. RESULTS: Eighty patients were initially enrolled. Two were converted and 4 required admission after being randomized to the OP group. Patients in the OP group received more oral pain medication prior to PACU discharge. Degree of pain, number of phone calls, readmission and complication rates, and patient satisfaction were similar between both groups. Of the 4 unexpected admissions, all were identified within the 4-h PACU stay. CONCLUSIONS: Patients undergoing laparoscopic cholecystectomy who are discharged home 4 h postoperatively will experience the same satisfaction with no increase in complications as patients admitted overnight.

Effects of helium pneumoperitoneum in pregnant ewes.

BACKGROUND: Previous animal studies have demonstrated that a carbon dioxide (CO(2)) pneumoperitoneum in pregnant ewes causes maternal and fetal acidosis, decreased uterine blood flow (UtBF), and fetal hypertension. This study was undertaken to determine whether helium (He) produces these same effects when used as an insufflating gas. METHODS: Six gravid ewes, at 116 to 120 days gestation, underwent catheterization of the maternal femoral artery and vein and the fetal hindlimb artery and vein, as well as insertion of a uterine artery flow probe. After a 6-day recovery period, the animals were anesthetized; a Hasson trocar was placed; and an He pneumoperitoneum was established (10 mmHg for 30 min followed by 15 mmHg for 30 min). The following parameters were recorded at baseline and at preset time points: maternal and fetal heart rate (HR), blood pressure (BP), arterial blood gasses, maternal end-tidal CO(2) (EtCO2), and UtBF. The percentage of change over time was determined for each variable. The results were compared with results previously obtained in control animals and in animals undergoing CO(2) pneumoperitoneum. Statistical significance was determined by repeated measures analysis of variance (ANOVA). RESULTS: The following statistically significant changes were found. CONCLUSIONS: Like CO(2), He used for pneumoperitoneum resulted in decreased UtBF and fetal hypertension because of increased intra-abdominal pressure. Unlike a CO(2), He used for pneumoperitoneum does not cause maternal or fetal acidosis, indicating that the metabolic effects seen with CO(2) are the result of the specific gas used. Therefore, He may be a safer gas than CO(2) to use for laparoscopic procedures in pregnant patients.

Special problems in laparoscopic surgery. Previous abdominal surgery, obesity, and pregnancy.

Previous surgery, obesity, and pregnancy should no longer be considered contraindications to laparoscopic surgery. Surgeons should exercise good judgement in patient selection, use meticulous surgical techniques, and prepare thoroughly for the planned procedure. Patients and surgeons should be aware of increased conversion rates. With these caveats in mind, these patients can still experience the advantages of minimally invasive surgery without increased risks.

Predictors of outcome in trauma during pregnancy: identification of patients who can be monitored for less than 6 hours.

BACKGROUND: The first objective of this study was to identify risk factors in pregnant patients suffering blunt trauma predictive for uterine contractions, preterm labor, or fetal loss. The second objective was to identify patients who can safely undergo fetal monitoring for 6 hours or less after blunt trauma by selecting out those patients demonstrating the identified risk factors. METHODS: A retrospective chart review was performed from January 1, 1990, through December 31, 1998. Charts were reviewed for numerous possible risk factors for adverse outcomes. Statistical analysis was performed by using logistic regression. RESULTS: A total of 271 pregnant patients admitted after blunt trauma were identified. Risk factors significantly predictive of fetal death included ejections, motorcycle and pedestrian collisions, maternal death, maternal tachycardia, abnormal fetal heart rate, lack of restraints, and Injury Severity Score > 9. Risk factors significantly predictive of contractions or preterm labor included gestational age >35 weeks, assaults, and pedestrian collisions. CONCLUSION: Pregnant patients who present after blunt trauma with any of the identified risk factors for contractions, preterm labor, or fetal loss should be monitored for at least 24 hours. Patients without these risk factors can safely be monitored for 6 hours after trauma before discharge.

Surgical practice of primary care physicians in a rural state: implications for curriculum design.

BACKGROUND: We surveyed practicing primary care physicians to help determine surgical practice patterns of primary care physicians in a rural state. The information obtained can be used to make surgical curriculum decisions for generalist medical students and primary care residents. METHODS: We developed a questionnaire in which practicing primary care physicians were asked to rate, on a 5-point Likert scale, the importance of 145 areas of surgical knowledge and 48 areas of clinical skills to their practice. Responses were rank ordered by the mean ratings for each individual item. The questionnaire was sent to all 876 primary care physicians in the home state of the institution. RESULTS: The survey response rate was 61% (n = 534). The most highly ranked items and procedures included acute otitis media, sinusitis, gastroesophageal reflux disease, pharyngitis, urinary tract infection, performance of abdominal exam, history and physical, daily progress notes, ear canal cleaning, and ability to write admission orders. The lowest ranked items included transplantation, infertility, amputations, performance of tracheostomy, venous cutdown, and cricothyrotomy. CONCLUSIONS: Information regarding the surgical practice patterns of practicing primary care physicians can be used to develop a surgical curriculum for medical students and primary care residents.

Laparoscopically assisted colon resection for colon carcinoma: perioperative results and long-term outcome.

BACKGROUND: The role of laparoscopic colon resection in the management of colon cancer is unclear. The aims of this study were to compare perioperative results and long-term outcomes in patients randomized to either open (O) or laparoscopically assisted (LA) colon resection for colon cancer. METHODS: A prospective randomized trial comparing O to LA colon resection was conducted from January 1993 to November 1995. Preoperative workup, intraoperative results, complications, length of stay, pathologic findings, and long-term outcomes were compared between the two groups. Statistical analysis was performed with t-test. Follow-up periods ranged from 3.5 to 6.3 years (mean, 4.9 years). RESULTS: No port-site or abdominal wall recurrences were noted in any patients. [table: see text] CONCLUSIONS: These results suggest that laparoscopically assisted colon resection for malignant disease can be performed safely, with morbidity, mortality, and en bloc resections comparable with those of open laparotomy. Long-term (5-year) follow-up assessment shows similar outcomes in both groups of patients, demonstrating definite perioperative advantages with LA surgery and no perioperative or long-term disadvantages.

Laparoscopic management of gastric diverticula.

Gastric diverticular are rare and usually are diagnosed incidentally on radiographic examination. Surgical treatment, consisting of simple excision or inversion of the diverticulum, has been reserved for patients with proven symptoms or complications. These procedures have typically required laparotomy, but with the development of advanced endoscopic techniques, a minimally invasive approach may be appropriate. The authors report two cases of gastric diverticula managed laparoscopically and review the literature related to this entity. Between 1993 and 1996, two patients were evaluated for dyspepsia-like gastrointestinal complaints. Both patients were found to have a gastric diverticulum on a contrast study, and one diverticulum was also seen on upper endoscopy. Laparoscopic resection was undertaken in both cases. Flexible gastroscopy was performed intraoperatively to help localize the diverticulum, which was resected with an endoscopic stapling device. Nissen fundoplication was performed in conjunction with the diverticulectomy in the second patient for gastroesophageal reflux. Both procedures were completed laparoscopically without complications. The postoperative course was uneventful in both patients. At long-term follow-up, the patients are asymptomatic. This experience indicates that laparoscopic resection of symptomatic gastric diverticula is a feasible alternative to laparotomy. A prospective analysis to verify the safety and efficacy of this procedure should be done.

University and practice-based physicians' input on the content of a surgical curriculum.

BACKGROUND: The specific knowledge and skills students learn during surgical rotations are reconsidered in light of recent changes in medical school curricula. The purpose of this study was to determine the priorities of a surgical curriculum based on input from three groups; surgical faculty (SF), primary care faculty (PCF), and community-based , practicing primary care physicians (PCP). METHODS: A questionnaire was developed in which SF (n=54), PCF (n=85), and PCP (n=876) were asked to rank the importance of 145 areas of knowledge and 48 areas of clinical skills on a 5-point Likert-type scale. Responses were rank ordered by the mean of importance ratings for each group. Differences among groups were evaluated using ANOVA. RESULTS: Response rates were best for faculty (100%) SF, 88% PCF, 61% PCP). All three groups were best considered general surgery related topics and general skills very important. Primary care physicians and PCF consistently ranked otolaryngology, ophthalmology, and orthopedic topics and skills higher than did SF. Surgery faculty ranked invasive surgical procedures higher than did PCP while PCP ranked orthopedic procedural skills more highly. CONCLUSIONS: There is significant overlap among physicians about what medical students should learn during surgical rotation. Differences between groups centered on surgical subspecialty knowledge and clinical skills. These results provide a broad perspective about required subjects for a core surgical clerkship curriculum, which should include surgical subspecialty training.

Laparoscopic reoperation for failed antireflux procedures.

BACKGROUND: Laparoscopic fundoplication has become the criterion standard for the surgical treatment of gastroesophageal reflux disease. Recently, several patients were referred with recurrent symptoms of gastroesophageal reflux disease or severe dysphagia following previous antireflux surgery for possible laparoscopic reoperation. HYPOTHESIS: To determine the safety and efficacy of this procedure. DESIGN: Case series, consecutive sample. SETTING: University-affiliated and community tertiary care hospitals. PATIENTS: Prospective study of 27 consecutive patients undergoing attempted laparoscopic reoperation for symptoms of recurrent gastroesophageal reflux disease or intractable dysphagia following antireflux surgery. Patients were available for follow-up for 1 to 60 months postoperatively. INTERVENTIONS: All patients underwent preoperative workup and attempted laparoscopic reoperation for treatment of symptoms. MAIN OUTCOME MEASURES: Data were collected on preoperative symptoms and evaluation, operative time, blood loss, time to regular diet, length of hospitalization, morbidity, mortality, and long-term results. RESULTS: Twenty-six patients underwent successful laparoscopic operations, with no mortality and minimal morbidity. One patient underwent conversion to open laparotomy and then developed a proximal gastric leak, which was treated conservatively. Twenty-four patients began a liquid diet by postoperative day 1, and most were discharged from the hospital by postoperative day 3. One patient required dilation for postoperative dysphagia. The remaining patients are doing well and none have required treatment with acid-reducing medication. CONCLUSIONS: Although technically challenging, laparoscopic reoperation for recurrent gastroesophageal reflux disease can be performed safely and with excellent results. In the hands of experienced endoscopic surgeons, patients who have undergone unsuccessful antireflux surgery should be offered laparoscopic reoperation.

Laparoscopic intraperitoneal onlay inguinal herniorrhaphy.

BACKGROUND: This study presents intermediate follow-up data on a randomized prospective series of patients undergoing either a modified laparoscopic intraperitoneal onlay mesh herniorrhaphy (IPOM) or conventional anterior inguinal herniorrhaphy (CH). METHODS: All patients from two university affiliated hospitals with primary or recurrent inguinal hernias were recruited for randomization to either the IPOM technique utilizing a meshed expanded polytetrafluorethylene (ePTFE) soft tissue patch or CH. Follow-up data were gathered from postoperative clinic visits and telephone and mail surveys. RESULTS: Previously reported early recurrence and complication rates at a mean follow-up of 8 months were 1 of 30 (3%) and 5 of 30 (17%) for IPOM, and 2 of 28 (7%) and 5 of 28 (18%) for CH. Intermediate follow-up with 50 (23 IPOM and 27 CH) of the original 58 patients (86%) at a mean of 41 months reveals a recurrence rate of 10 of 23 (43%) for the IPOM group and 4 of 27 (15%) for the CH group (P = 0.053). Five delayed complications occurred in 4 IPOM patients (port site hernia 4, painful neuroma 1), while 2 delayed complications (unilateral testicular atrophy 2) occurred in 2 patients in the CH group. One IPOM versus 5 CH patients subsequently developed previously unrecognized contralateral hernias. There was 1 death unrelated to previous herniorrhaphy in each group. CONCLUSIONS: IPOM recurrence rates (43%) at a mean follow-up of 41 months are excessively high when compared with CH (15%) or with preliminary results of IPOM at 8 months of follow-up (3%). Despite reduced perioperative pain and disability and promising preliminary results in the IPOM group, these intermediate follow-up data strongly suggest that the IPOM technique should not be used for repair of inguinal hernias.

Adhesion formation in laparoscopic inguinal hernia repair.

BACKGROUND: In laparoscopic inguinal hernia repair controversy exists concerning the most appropriate repair method and implant material to use if intraabdominal adhesions are to be minimized. METHODS: In 108 pigs, we implanted three different types of mesh by both the TAPP (transabdominal preperitoneal) and Onlay (prosthesis placed directly upon the peritoneum) methods. Specimens were harvested in three time periods and adhesion formation was compared. RESULTS: Average adhesions at 3 days were TAPP 18% and Onlay 49% (p < 0.001). At 3 weeks average adhesions were TAPP 8% and Onlay 23% (p < 0.04). Three-month figures were TAPP 1% and Onlay 13% (p < 0.001). In contrast, there were no differences in adhesion formation due to material type in any of the three time periods (all p > 0.17). CONCLUSIONS: A peritoneal covering over a laparoscopic inguinal implant significantly reduced adhesions. Prosthetic material type did not affect adhesion formation in this study.

Force sensor for laparoscopic Babcock.

UNLABELLED: GENERAL: A force sensor has been designed and fabricated that will fit to existing laparoscopic grasping forceps (Babcocks) from Ethicon Endosurgery Inc. The goal of the sensor development is to provide tool-tissue force information to the surgeons so that surgeons can regain the sense of touch that has been lost through laparoscopy. Eventually, force sensing will provide feedback for robotic laparoscopic surgical platforms. OBJECTIVE: We have developed a prototype force sensor system with ATI Industrial Automation. This tool is provided as an in-line transducer with six degrees of freedom that can retrofit current Babcocks. The sensor is currently being used in clinical trials with animals to determine the benefits. The sensor system utilizes industry proven technology in combination with a custom transducer and user interface. A GUI is part of the system and provides resolved force magnitude data in a graphical format for case of interpretation. Sterilization, size, and ease of use are addressed by the current design. Operating room reliability and safety are currently being investigated. CLINICAL TRIAL: A three phase experimental trial using a porcine model is being completed that will test the hypothesis that force information can be used to minimize tissue trauma during laparoscopic surgery. RESULTS: Based on our research, there is strong evidence that surgeons would benefit from information regarding the levels of force applied to tissues. In the future, robotic surgery will require force sensing. Surgical simulators could provide force feedback during simulated surgical procedures by using a sensor platform such as this. In addition, tool tip design in the future will benefit from the application of this technology and data base.

A comparison of the pathophysiologic effects of carbon dioxide, nitrous oxide, and helium pneumoperitoneum on intracranial pressure.

BACKGROUND: Previous studies have suggested that diagnostic laparoscopy may be contraindicated in multiple trauma patients with closed head injuries because of the detrimental effects of carbon dioxide (CO2) pneumoperitoneum on intracranial pressure (ICP). In this study we compared the effects of two alternative inflation gases, helium (He) and nitrous oxide (N2O), against the standard agent used in most hospitals, CO2. ICP was monitored in experimental animals both with and without a space occupying intracranial lesion designed to simulate a closed head injury. METHODS: Twenty-four domestic pigs (mean, 30 kg) were divided into four groups (6 CO2, 6 He, 6 N2O, and 6 control animals without insufflation). All animals were monitored for ICP, intraabdominal pressure, mean arterial pressure, end-tidal CO2 (ETCO2), and arterial blood gases. These parameters were measured for 30 minutes prior to introducing a pneumoperitoneum and then for 80 minutes thereafter. The measurements were repeated after artificially elevating the ICP with a balloon placed in the epidural space. RESULTS: The mean ICP increased significantly in all groups during peritoneal insufflation compared with the control group (P < 0.005). The CO2-insufflated animals also showed a significant increase in PaCO2 (P < 0.05) and ETCO2 (P < 0.05), as well as a decrease in pH (P < 0.05). After inflating the epidural balloon the ICP remained significantly higher in animals inflated with CO2 as compared with the He and N2O groups (P < 0.05). CONCLUSIONS: Peritoneal insufflation with He and N2O resulted in a significantly less increase in ICP as compared with CO2. That difference was most likely due to a metabolically mediated increase in cerebral perfusion (PaCO2) in the CO2 group. Further studies need to be conducted to determine the safety and efficacy of using He and N2O as inflation agents prior to attempting diagnostic or therapeutic laparoscopy in patients with potential closed head injuries.

Effects of CO2 pneumoperitoneum in pregnant ewes.

Laparoscopy has been considered a relative contraindication in pregnant patients because the CO2 pneumoperitoneum may cause maternal and/or fetal hypotension, acidosis, hypercarbia, hypoxia, changes in cardiac output, or uterine artery blood flow. These potential changes were studied in an established animal pregnancy model. Twelve gravid ewes (116-120 days gestation) underwent catheterization of maternal femoral artery and vein, fetal hindlimb artery and vein, insertion of a uterine artery flow probe, and pulmonary artery catheter. Six animals underwent creation of a CO2 pneumoperitoneum (10 mm Hg for 30 min; 15 mm Hg for 30 min). Six control animals were studied without a pneumoperitoneum. The following parameters were recorded at baseline and at preset time points: cardiac output (CO), uterine blood flow (UtBF), amniotic cavity pressure (ACP), end-tidal CO, (Et CO2), maternal and fetal heart rate (HR), blood pressure (BP), and lactate, glucose, and arterial blood gasses. Percent change at each time point compared to baseline was determined for each variable. Statistical significance was determined by repeated measures analysis of variance. No changes were found between study and control animals in maternal BP; CO; lactate, glucose, oxygenation, or fetal HR; oxygenation, lactate, or glucose. Statistically significant differences (P < 0.01) between study and control animals were noted in ACP, Et CO2, MHR, UtBF, FBP, and Maternal/fetal pH, PCO2. All ewes delivered healthy lambs at full gestation. A CO2 pneumoperitoneum up to 15 mm Hg pressure in gravid ewes causes increased intrauterine pressure, decreased UtBF, and induces maternal and fetal acidosis. Despite these intraoperative deleterious effects, long-term fetal well being was not effected.

Laparoscopy during pregnancy.

OBJECTIVE: To compare the safety and efficacy of laparoscopic surgery with that of open laparotomy in pregnant patients. DESIGN: Six-year case-control study. SETTING: Tertiary care, university and community hospitals. PATIENTS: Population-based sample. From 1990 through 1995, 16 pregnant patients underwent laparoscopic surgery (study group) and 18 underwent open laparotomy (control group) during the first or second trimester. Follow-up ranged from 1 month to 6 years. INTERVENTION: In the study group, 4 patients underwent appendectomies and 12 underwent cholecystectomies. The control group included 7 appendectomies and 11 cholecystectomies. MAIN OUTCOME MEASURES: The 2 groups were compared for age, trimester, surgical time, oxygen saturation, end-tidal carbon dioxide, return of gastrointestinal tract function, duration of intravenous or intramuscular narcotics, postoperative stay, gestational age of delivery, 1- and 5-minute Apgar scores, birth weights, and complications. RESULTS: Age, trimester, oxygenation, end-tidal CO2, gestational age at delivery, Apgar scores, and birth weights were not different between the 2 groups. The patients who underwent laparoscopy had significantly longer operative times 82 vs 49 minutes), shorter stay (1.5 vs 2.8 days), earlier resumption of regular diet (1.0 vs 2.4 days), and shorter duration of intravenous or intramuscular narcotics (1.2 vs 2.6 days) (all P < .01). Four complications were found in the laparotomy group vs 6 in the laparoscopy group. CONCLUSIONS: Laparoscopic surgery in pregnant women significantly decrease hospitalization, decreases narcotic use, and quickens return to a regular diet when compared with open laparotomy in pregnant women. No significant differences between the 2 groups in perioperative morbidity or mortality were present. These data suggest that therapeutic laparoscopy during pregnancy in the first or second trimester is safe.

Successful laparoscopic repair of paraesophageal hernia.

OBJECTIVE: To evaluate prospectively the safety and efficacy of laparoscopic surgical techniques in the repair of types II and III paraesophageal hernias. DESIGN: Case series. SETTING: Tertiary-care, university-affiliated hospitals. PATIENTS: Twelve consecutive patients undergoing elective laparoscopic repair of type II or type III paraesophageal hernias. Patients were available for follow-up for 1 to 17 months postoperatively. INTERVENTIONS: All patients underwent laparoscopic paraesophageal hernia reduction and repair. Eight patients with gastroesophageal reflux disease underwent concurrent laparoscopic Nissen fundoplication. MAIN OUTCOME MEASURES: Operative times, operative complications, and estimated blood loss were recorded. Postoperative outcome measurements included length of hospital stay, postoperative complications, postoperative gastrointestinal tract symptoms, and patient satisfaction. RESULTS: All patients had successful completion of paraesophageal hernia repair laparoscopically with no recurrences, and with an overall minor morbidity rate of 25%, major morbidity rate of 8%, and no deaths. Eight of 12 patients with concomitant reflux disease underwent successful laparoscopic Nissen fundoplication with complete control of reflux symptoms. The average hospital stay for patients with uncomplicated courses was 2.5 days. Long-term (> 6 weeks) postfundoplication symptoms occurred in 13% of those patients who underwent fundoplication. Eleven (92%) of 12 patients described good to excellent results with complete or near complete control of all preoperative symptoms. CONCLUSIONS: Laparoscopic repair of types II and III paraesophageal hernias can be performed under elective circumstances by experienced laparoscopic surgeons, with acceptable morbidity and comparable short-term efficacy. Addition of a concomitant antireflux procedure should be reserved for those patients with clear preoperative evidence of reflux disease secondary to a mechanically defective lower esophageal sphincter. Patients with a normal lower esophageal antireflux barrier do not need a concomitant antireflux procedure.

Laparoscopic antegrade sphincterotomy. A new technique for the management of complex choledocholithiasis.

OBJECTIVE: Laparoscopic antegrade sphincterotomy represents a new technique that expands the ability of the surgeon to manage complex choledocholithiasis at the time of laparoscopic cholecystectomy. The authors describe their experience with six patients with cholelithiasis and complex common bile duct stone disease who underwent successful laparoscopic cholecystectomy and antegrade sphincterotomies. SUMMARY BACKGROUND DATA: Patients with complex choledocholithiasis have represented a technical challenge to the minimally invasive surgeon. Recently, a laparoscopic technique of antegrade biliary sphincterotomy has been reported by DePaulo in Brazil. This technique has been successful at clearing the common bile duct at the time of laparoscopic cholecystectomy. METHODS: Laparoscopic antegrade sphincterotomy was performed in six patients with multiple common bile duct stones. A standard endoscopic sphincterotome was introduced antegrade via the cystic duct or common bile duct and guided through the ampulla. A side-viewing duodenoscope was used to confirm proper positioning of the sphincterotome. Then a blended current was applied until the sphincterotomy was complete. RESULTS: There was no mortality or morbidity associated with laparoscopic antegrade sphincterotomy. The mean additional operative time to complete laparoscopic antegrade sphincterotomy was 19 minutes. Three of the six patients were noted to have transient, asymptomatic elevation in serum amylase levels immediately after surgery (average 252 international units/L; normal < 115), which normalized within 72 hours. The mean postoperative hospital stay was 2.9 days. At a mean follow-up of 5 months (range 1 to 10 months), five patients remain asymptomatic. One individual with acquired immune deficiency syndrome had persistent symptoms, and a diagnosis of cytomegalovirus pancreatitis was eventually made. CONCLUSIONS: Laparoscopic antegrade sphincterotomy appears to be a safe and effective technique for the management of complex biliary tract disease.