Side-to-side duodeno-ileal magnetic compression anastomosis: design and feasibility of a novel device in a porcine model.

BACKGROUND: Minimally invasive metabolic/bariatric surgery (MBS) may be further advanced by magnetic compression anastomosis (MCA) technology. The study aimed to develop a magnet sized to create a patent duodeno-ileostomy (DI) and verify its effectiveness in a porcine model. METHODS: Developmental study phase: magnets with 4 different flange-offset dimensions were tested to identify a design that would successfully form a compression anastomosis. Verification phase: evaluation of the selected design's efficacy. In each 6-week phase (4 pigs/phase), one magnet was inserted laparoscopically in the jejunum, one placed gastroscopically in the duodenum. Magnets were aligned, gradually fused, formed an anastomosis, and then detached and were expelled. At necropsy, MCA sites and sutured enterotomy sites were collected and compared. RESULTS: Developmental phase: the linear BC42 magnet with a 2.3-mm flange offset design was selected. Verification phase: in 4 swine magnets were mated at the target location, confirmed radiographically. Mean time to magnet detachment 16.0 days (12-22), to expulsion 24.5 days (17-33). MCA was achieved in all animals at time of sacrifice. Animals gained a mean 9.5 kg (3.9-11.8). Specimens revealed patent anastomoses of ≥ 20 mm with smooth mucosa and minimal inflammation and fibrosis compared to sutured enterotomies. One pig underwent corrective surgery for a mesenteric hernia without sequelae. CONCLUSION: In a large-animal model, gross and histopathologic examination confirmed that the linear MCA device created a patent, well-vascularized, duodeno-ileal anastomosis. The novel MCA device may be appropriate for use in human MBS procedures.

Prescription and consumption of opioids after bariatric surgery: a multicenter prospective cohort study.

INTRODUCTION: In the current opioid crisis, bariatric surgical patients are at increased risk of harms related to postoperative opioid overprescribing. This study aimed to assess the extent to which opioids prescribed at discharge after bariatric surgery are consumed by patients. METHODS: This multicenter prospective cohort study included adult patients (≥ 18yo) undergoing laparoscopic bariatric surgery. Preoperative assessments included demographics and patient-reported measures. Information regarding surgical and perioperative care interventions (including discharge prescriptions) was obtained from medical records. Self-reported opioid consumption was assessed weekly up to 30 days post-discharge. Number of opioid pills prescribed and consumed was compared using Wilcoxon signed-rank test. Zero-inflated negative binomial regression was used to identify predictors of post-discharge opioid consumption. RESULTS: We analyzed 351 patients (mean age 44 ± 11 years, BMI 45 ± 8.0 kg/m2, 77% female, 71% sleeve gastrectomy, length of stay 1.6 ± 0.6 days). The quantity of opioids prescribed at discharge (median 15 pills [IQR 15-16], 112.5 morphine milligram equivalents (MMEs) [IQR 80-112.5]) was significantly higher than patient-reported consumption (median 1 pill [IQR 0-5], 7.5 MMEs [IQR 0-37.5]) (p < 0.001). Overall, 37% of patients did not take any opioids post-discharge and 78.5% of the opioid pills prescribed were unused. Increased post-discharge opioid consumption was associated with male sex (IRR 1.54 [95%CI 1.14 to 2.07]), higher BMI (1.03 [95%CI 1.01 to 1.05]), preoperative opioid use (1.48 [95%CI 1.04 to 2.10]), current smoking (2.32 [95%CI 1.44 to 3.72]), higher PROMIS-29 depression score (1.03 [95% CI 1.01 to 1.04]), anastomotic procedures (1.33 [95%CI 1.01 to 1.75]), and number of pills prescribed (1.04 [95%CI 1.01 to 1.06]). CONCLUSION: This study supports that most opioid pills prescribed to bariatric surgery patients at discharge are not consumed. Patient and procedure-related factors may predict opioid consumption. Individualized post-discharge analgesia strategies with minimal or no opioids may be feasible and should be further investigated in future research.

Predictors of post-discharge pain and satisfaction with pain management after laparoscopic bariatric surgery: a prospective cohort study.

BACKGROUND: Pain management after bariatric surgery remains challenging given the risk for analgesia-related adverse events (e.g., opioid use disorder, marginal ulcers). Identifying modifiable factors associated with patient-reported pain outcomes may improve quality of care. We evaluated the extent to which patient and procedural factors predict 7-day post-discharge pain intensity, pain interference, and satisfaction with pain management after bariatric surgery. METHODS: This prospective cohort study included adults undergoing laparoscopic bariatric surgery at two university-affiliated hospitals and one private clinic. Preoperative assessments included demographics, Pain Catastrophizing Scale (score range 0-52), Patient Activation Measure (low [< 55.1] vs. high [≥ 55.1]), pain expectation (0-10), and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) anxiety and depression scales. At 7 days post-discharge, assessments included PROMIS-29 pain intensity (0-10) and pain interference scales (41.6-75.6), and satisfaction with pain management (high [10-9] vs. lower [8-0]). Linear and logistic regression were used to assess the association of pain outcomes with potential predictors. RESULTS: Three hundred and fifty-one patients were included (mean age = 44 ± 11 years, BMI = 45 ± 8 kg/m2, 77% female, 71% sleeve gastrectomy). At 7 days post-discharge, median (IQR) patient-reported pain intensity was 2.5 (1-5), pain interference was 55.6 (52.0-61.2), and 76% of patients reported high satisfaction with pain management. Pain intensity was predicted by preoperative anxiety (ß + 0.04 [95% CI + 0.01 to + 0.07]) and pain expectation (+ 0.15 [+ 0.05 to + 0.25]). Pain interference was predicted by preoperative anxiety (+ 0.22 [+ 0.11 to + 0.33]), pain expectation (+ 0.47 [+ 0.10 to + 0.84]), and age (- 0.09 [- 0.174 to - 0.003]). Lower satisfaction was predicted by low patient activation (OR 1.94 [1.05-3.58]), higher pain catastrophizing (1.03 [1.003-1.05]), 30-day complications (3.27 [1.14-9.38]), and age (0.97 [0.948-0.998]). CONCLUSION: Patient-related factors are important predictors of post-discharge pain outcomes after bariatric surgery. Our findings highlight the value of addressing educational, psychological, and coping strategies to improve postoperative pain outcomes.

Side-to-side magnet anastomosis system duodeno-ileostomy with sleeve gastrectomy: early multi-center results.

INTRODUCTION: Gastrointestinal anastomoses with classical sutures and/or metal staples have resulted in significant bleeding and leak rates. This multi-site study evaluated the feasibility, safety, and preliminary effectiveness of a novel linear magnetic compression anastomosis device, the Magnet System (MS), to form a side-to-side duodeno-ileostomy (DI) diversion for weight loss and type 2 diabetes (T2D) resolution. METHODS: In patients with class II and III obesity (body mass index [BMI, kg/m2] ≥ 35.0- ≤ 50.0 with/without T2D [HbA1C > 6.5%]), two linear MS magnets were delivered endoscopically to the duodenum and ileum with laparoscopic assistance and aligned, initiating DI; sleeve gastrectomy (SG) was added. There were no bowel incisions or retained sutures/staples. Fused magnets were expelled naturally. Adverse events (AEs) were graded by Clavien-Dindo Classification (CDC). RESULTS: Between November 22, 2021 and July 18, 2022, 24 patients (83.3% female, mean ± SEM weight 121.9 ± 3.3 kg, BMI 44.4 ± 0.8) in three centers underwent magnetic DI. Magnets were expelled at a median 48.5 days. Respective mean BMI, total weight loss, and excess weight loss at 6 months (n = 24): 32.0 ± 0.8, 28.1 ± 1.0%, and 66.2 ± 3.4%; at 12 months (n = 5), 29.3 ± 1.5, 34.0 ± 1.4%, and 80.2 ± 6.6%. Group mean respective mean HbA1C and glucose levels dropped to 1.1 ± 0.4% and 24.8 ± 6.6 mg/dL (6 months); 2.0 ± 1.1% and 53.8 ± 6.3 mg/dL (12 months). There were 0 device-related AEs, 3 procedure-related serious AEs. No anastomotic bleeding, leakage, stricture, or mortality. CONCLUSION: In a multi-center study, side-to-side Magnet System duodeno-ileostomy with SG in adults with class III obesity appeared feasible, safe, and effective for weight loss and T2D resolution in the short term.

The initiation, standardization and proficiency (ISP) phases of the learning curve for minimally invasive liver resection: comparison of a fellowship-trained surgeon with the pioneers and early adopters.

BACKGROUND: Using the Ideal Development Exploration Assessment and Long-term study (IDEAL) paradigm, Halls et al. created risk-adjusted cumulative sum (RA-CUSUM) curves concluding that Pioneers (P) and Early Adopters (EA) of minimally invasive (MI) liver resection obtained similar results after fewer cases. In this study, we applied this framework to a MI Hepatic-Pancreatic and Biliary fellowship-trained surgeon (FT) in order to assess where along the curves this generation fell. METHODS: The term FT was used to designate surgeons without previous independent operative experience who went from surgical residency directly into fellowship. Three phases of the learning curve were defined using published data on EAs and Ps of MI Hepatectomy, including phase 1 (initiation) (i.e., the first 17 or 50), phase 2 (standardization) (i.e., cases 18-46 or 1-50) and phase 3 (proficiency) (i.e., cases after 46, 50 or 135). Data analysis was performed using the Social Science Statistics software ( www.socscistatistics.com ). Statistical significance was defined as p < .05. RESULTS: From November 2007 until April 2018, 95 MI hepatectomies were performed by a FT. During phase 1, the FT approached larger tumors than the EA group (p = 0.002), that were more often malignant (94.1%) when compared to the P group (52.5%) (p < 0.001). During phase 2, the FT operated on larger tumors and more malignancies (93.1%) when compared to the Ps (p = 0.004 and p = 0.017, respectively). However, there was no difference when compared to the EA. In the phase 3, the EAs tended to perform more major hepatectomies (58.7) when compared to either the FT (30.6%) (p = 0.002) or the P's cases 51-135 and after 135 (35.3% and 44.3%, respectively) (both p values < 0.001). When compared to the Ps cases from 51-135, the FT operated on more malignancies (p = 0.012), but this was no longer the case after 135 cases by the Ps (p = 0.164). There were no statistically significant differences when conversions; major complications or 30- and 90-day mortality were compared among these 3 groups. DISCUSSION: Using the IDEAL framework and RA-CUSUM curves, a FT surgeon was found to have curves similar to EAs despite having no previous independent experience operating on the liver. As in our study, FTs may tend to approach larger and more malignant tumors and do more concomitant procedures in patients with higher ASA classifications than either of their predecessors, without statistically significant increases in major morbidity or mortality. CONCLUSION: It is possible that the ISP (i.e., initiation, standardization, proficiency) model could apply to other innovative surgical procedures, creating different learning curves depending on where along the IDEAL paradigm surgeons fall.

The experience of the minimally invasive (MI) fellowship-trained (FT) hepatic-pancreatic and biliary (HPB) surgeon: could the outcome of MI pancreatoduodenectomy for peri-ampullary tumors be better than open?

BACKGROUND: Although early series focused on benign disease, minimally invasive pancreatoduodenectomy (MIPD) might be particularly suited for malignancy. Unlike their predecessors, fellowship-trained (FT) Hepatic-Pancreatic and Biliary (HPB) surgeons usually have equal skills in approaching peri-ampullary tumors (PT) either openly or via minimally invasive (MI) techniques. METHOD: We retrospectively reviewed a MI-HPB-FT surgeon's 10-year experience with PD. A sub-analysis of malignant PT was also done (MIPD-PT vs. OPD-PT). The primary endpoint was to assess postoperative mortality and morbidity. Secondary endpoints included operative parameters, length of hospital stay, and survival analysis. Moreover, we addressed practice pattern changes for a surgeon straight out of training with no previous experience of independent surgery. RESULTS: From December 2007-February 2018, one MI-HPB-FT performed a total of 100 PDs, including 57 MIPDs and 43 open PDs (OPDs). In both groups, over 70% of PDs were undertaken for malignancy. Eight patients with borderline resectable pancreatic ductal cancer (PDC) were in the OPD-PT group (as compared to only 2 in the MIPD-PT group) (p = 0.07). Estimated mean blood loss and length of stay were less in the MIPD-PT group (345 mL and 12 days) as compared to the OPD-PT group (971 mL and 16 days), p < 0.001 and p = 0.007, respectively. However, the mean operative time was longer for the MIPD-PT (456 min) as compared to the OPD-PT (371 min), p < 0.001. Thirty and 90-day mortality was 2.6%/5.1% after MIPD-PT compared to 0%/3.2% after OPD-PT, respectively, p = 1. Overall 30-/90-day morbidity rates were similar at 41.0%/43.6% after MIPD-PT and 35.5%/41.9% after OPD-PT, respectively, p = 0.8 and 1. Complete resection (R0) rates were not statistically different, 97.4% after MIPD-PT compared to 87.0% after OPD-PT (p = 0.2). After MIPD and OPD for malignant PT, overall 1, 3 and 5-year survival rates, and median survival were 82.5%, 59.6% and 46.3% and 38 months as compared to 52.5%, 15.7% and 10.5% and 13 months, respectively (p = 0.01). In the MIDP-PT group, recurrence free survival (RFS) at 1, 3 and 5 years and median RFS were 69.1%, 41.9% and 33.5% and 26 months as compared to 50.4%, 6.3% and 6.3% and 13 months, in the OPD-PT group, respectively (p = 0.03). CONCLUSION: FT HPB Surgeons who begin their practice with the ability to do both MI and OPD may preferentially approach resectable peri-ampullary tumors minimally invasively. This may result in decreased blood loss decreased length of hospital stays. Despite longer operative time, the improved visualization of MI techniques may enable superior R0 rates when compared to historical open controls. Moreover, combined with quicker initiation of adjuvant chemotherapeutic treatments, this may eventually result in improved survival.

Comparison of laparoscopic sleeve gastrectomy leak rates in five staple-line reinforcement options: a systematic review.

BACKGROUND: Staple-line leaks following laparoscopic sleeve gastrectomy (LSG) remain a concerning complication. Staple-line buttressing is largely adopted as an acceptable reinforcement but data regarding leaks have been equivocal. This study compared staple-line leaks in five reinforcement options during LSG: no reinforcement (NO-SLR), oversewing (suture), nonabsorbable bovine pericardial strips (BPS), tissue sealant or fibrin glue (Seal), or absorbable polymer membrane (APM). METHODS: This systematic review study of articles published between 2012 and 2016 regarding LSG leak rates aligned with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Variables of interest included leak rates, bleeding, and complications in addition to surgical and population parameters. An independent Fisher's exact test was used to compare the number of patients with and without leaks for the different reinforcement options. RESULTS: Of the 1633 articles identified, 148 met inclusion criteria and represented 40,653 patients. Differences in age (older in APM; p = 0.001), starting body mass index (lower in Suture; p = 0.008), and distance from pylorus (closer in BPS; p = 0.04) were observed between groups, but mean bougie size was equivalent. The overall leak rate of 1.5% (607 leaks) ranged from 0.7% for APM (significantly lower than all groups; p ≤ 0.007 for next lowest leak rate) to 2.7% (BPS). CONCLUSIONS: This systematic review of staple-line leaks following LSG demonstrated a significantly lower rate using APM staple-line reinforcement as compared to oversewing, use of sealants, BPS reinforcement, or no reinforcement. Variation in surgical technique may also contribute to leak rates.

Single-Port Sleeve Gastrectomy Compared With Conventional Laparoscopic Sleeve Gastrectomy: 5-Year Follow-up of Weight Loss, Comorbidity Resolution, and Cost.

Background. The Single-Port Instrument Delivery Extended Reach (SPIDER) surgical system is a safe revolutionary technology that defeated difficulties of single-incision surgery. We assessed the long-term outcomes of SPIDER sleeve gastrectomy (SPIDER SG) versus conventional laparoscopic sleeve gastrectomy (LSG) in morbidly obese patients. Methods. Retrospective review of patients who underwent SPIDER SG or LSG in our center matched by the date of surgery (2012-2013). We reviewed weight loss results up to 5 years, complication rates, procedure and hospitalization durations, financial cost, and effect on comorbidities. Results. Patients underwent 200 SPIDER SG and 220 LSG. At baseline, SPIDER SG versus LSG patients had a mean body mass index of 43.8 ± 5.6 and 48.6 ± 8.1 kg/m2, respectively. At 1 year, both groups had comparable percentage of excess weight loss (%EWL). At 5 years, SPIDER SG had %EWL of 54.6 ± 24.8 compared with 57.8 ± 29.9 in LSG (P = .4). Nine SPIDER SG (4.5%) required conversion to LSG. Complications occurred in both groups: 4% versus 4.1% (P = .95). At 2-year follow-up, diabetes mellitus was reversed in 43% of SPIDER SG and 62% LSG. Despite a shorter hospital stay in SPIDER SG, the total cost was significantly higher ($2 041 477) compared with LSG ($1 773 834). The mean score of scar satisfaction was significantly more in SPIDER SG. Conclusions. SPIDER SG was safe with long-term effects on weight loss comparable to LSG. Despite the higher cost of SPIDER SG, a shorter hospital stay and better cosmesis were observed.

Cost analysis of leak after sleeve gastrectomy.

BACKGROUND: Leaks after laparoscopic sleeve gastrectomy (LSG) are serious complications of this procedure. The objective of the present study was to evaluate the costs of leaks after LSG. SETTING: Private hospital, France. METHODS: A retrospective analysis was conducted on a prospective cohort of 2012 cases of LSG between September 2005 and December 2014. Data were collected on all diagnostic and therapeutic measures necessary to manage leaks, ward, and intensive care unit (ICU) length of stay. Additional outpatient care was also analyzed. RESULTS: Twenty cases (0.99%) of gastric leak were recorded. Fifteen patients had available data for cost analysis. Of these, 13 patients were women (86.7%) with a mean age of 41.4 years (range 22-61) and mean BMI of 43.2 kg/m2 (range 34.8-57.1). The leaks occurred after 7.4 days (±2.3) postoperatively. Only one gastric leak was recorded for the last 800 cases in which absorbable staple line reinforcement was used. Mean intra-hospital cost was 34398 € (range 7543-91,632 €). Prolonged hospitalization in ICU accounted for the majority of hospital costs (58.9%). Mean additional outpatient costs for leaks were 41,284 € (range 14,148-75,684€). CONCLUSIONS: Leaks after LSG are an expensive complication. It is therefore important to take all necessary measures to reduce their incidence. Our data should be considered when analyzing the cost effectiveness of staple line reinforcement usage.

Bariatric surgery tourism hidden costs? How Canada is not doing its part in covering bariatric surgery under the Canada Health Act.

SUMMARY: Many Canadians seek medical treatment outside our borders. Waiting times, rather than lack of expertise, are the number one culprit, and with globalization of health care, the number of patients who travel to obtain medical care will continue to rise. Though the provinces have covered the costs of complications from surgeries performed abroad for many years, complications from bariatric surgery performed abroad have been receiving negative attention. This commentary discusses associated costs and questions how the Canada Health Act should be covering bariatric procedures.

Comparison between orogastric tube/bougie and a suction calibration system for effects on operative duration, staple-line corkscrewing, and esophageal perforation during laparoscopic sleeve gastrectomy.

INTRODUCTION: Placement of a bougie for sleeve sizing during laparoscopic sleeve gastrectomy (LSG) is recommended. We compared this standard with a suction calibration system (SCS) that performs all functions with one insertion, and measured each step's duration. METHODS: Primary LSG was performed using a bougie and SCS in alternating order. Number of tube movements to achieve optimal placement, durations of decompression, leak testing, and overall operative time, and remnant linear measurements were obtained. RESULTS: LSG was performed in 26 patients (15 women, 11 men; mean age 36.8 years; mean BMI 45.3 kg/m(2)). The mean number of tube movements was significantly greater for the bougie than for the SCS (8.13 vs. 3.58; p < 0.0001). Percent reductions achieved using the SCS were: time to full decompression of the stomach, 62% (21 vs. 8 s; p < 0.138); tube placement, 51% (101 vs. 49 s; p < 0.0001); leak testing, 78% (119 vs. 26 s; p < 0.0003); and mean operative duration (from tube insertion to end of stapling), 21% (875 vs. 697 s; p < 0.019). Variance of the staple-line distance, measured from the greater curvature to the staple line, was 1.64 and 0.92 for the bougie and SCS, respectively, indicating a reduction in corkscrewing, for a 43.9% straighter sleeve. CONCLUSION: SCS maintained the gastric wall in place, thereby preventing corkscrewing, and reducing total operating time. Reducing the number of tube insertions may prevent esophageal damage and accidental tube stapling.

Revised sleeve gastrectomy: another option for weight loss failure after sleeve gastrectomy.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is becoming a very common bariatric procedure, based on several advantages it carries over more complex bariatric procedures such as gastric bypass or duodenal switch (DS), and a better quality of life over gastric banding. However, in the long-term follow-up, weight loss failure and intractable severe reflux after primary LSG can necessitate further surgical interventions, and revisional sleeve gastrectomy (ReSG) can represent an option to correct these. METHODS: From October 2008 to June 2013, 36 patients underwent an ReSG for progressive weight regain, insufficient weight, or severe gastroesophageal reflux in 'La Casamance' Private Hospital. All patients with weight loss failure after primary LSG underwent radiological evaluation. If Gastrografin swallow showed a huge unresected fundus or an upper gastric pouch dilatation, or if the computed tomography (CT) scan volumetry revealed a gastric tube superior to 250 cc, ReSG was proposed. RESULTS: Thirty-six patients (34 women, two men; mean age 41.3 years) with a body mass index (BMI) of 39.9 underwent ReSG. Thirteen patients (36.1 %) had their original LSG surgery performed at another hospital and were referred to us for weight loss failure. Twenty-four patients (66.6 %) out of 36 had a history of gastric banding with weight loss failure. Thirteen patients (36.1 %) were super-obese (BMI > 50) before primary LSG. The LSG was realized for patients with morbid obesity with a mean BMI of 47.1 (range 35.4-77.9). The mean interval time from the primary LSG to ReSG was 34.5 months (range 9-67 months). The indication for ReSG was insufficient weight loss for 19 patients (52.8 %), weight regain for 15 patients (41.7 %), and 2 patients underwent ReSG for invalidating gastroesophageal reflux disease. In 24 cases the Gastrografin swallow results were interpreted as primary dilatation, and in the remaining 12 cases results were interpreted as secondary dilatation. The CT scan volumetry was realized in 21 cases, and it has revealed a mean gastric volume of 387.8 cc (range 275-555 cc). All 36 cases were completed by laparoscopy with no intraoperative incidents. The mean operative time was 43 min (range 29-70 min), and the mean hospital stay was 3.9 days (range 3-16 days). One perigastric hematoma was recorded. The mean BMI decreased to 29.2 (range 20.24-37.5); the mean percentage of excess weight loss was 58.5 % (±25.3) (p < 0.0004) for a mean follow-up of 20 months (range 6-56 months). CONCLUSIONS: The ReSG may be a valid option for failure of primary LSG for both primary or secondary dilatation. Long-term results of ReSG are awaited to prove efficiency. Further prospective clinical trials are required to compare the outcomes of ReSG with those of Roux en Y Gastric Bypass or DS for weight loss failure after LSG.

Long-term outcome of laparoscopic resection for stage IV colorectal cancer.

Laparoscopic surgery is recommended as an initial stage IV colorectal cancer therapy. A 57-year-old male with sigmoid colon cancer and two hepatic metastases underwent laparoscopic sigmoidectomy with lymph adenectomy. He was orally administered postoperative Tagafur/Uracil/leucovorin therapy for 10 months. However, because of regrowth of the liver metastasis he was administered leucovorin/bolus and infusional 5-fluorouracil/irinotecan therapy for 10 months followed by extended left lobectomy of the liver and the above mentioned chemotherapy was continued for 6 months. He was diagnosed with S6 and S6/7 hepatic recurrent tumor, which were resected 14 months after the second and another 14 months after the third surgery, respectively. Forty-two months following complete response after the fourth surgery, S6 hepatic recurrent tumor was resected. Six months after the fifth surgery, he developed multiple liver metastases. He was treated successfully using leucovorin/bolus and infusional 5-fluorouracil/oxaliplatin and bevacizumab. He is alive 9 years and 3 months after initial surgery.

Impact of laparoscopic surgery on survival of patients with small bowel adenocarcinoma and peritoneal metastasis.

The feasibility of laparoscopic surgery for peritoneal metastasis is still controversial. A 42-year-old male presenting with bloody stool underwent small intestinal fiberscopic examination. The biopsied specimens pathologically demonstrated adenocarcinoma of the upper jejunum. Laparoscopy revealed a 10-mm nodule in the omentum. Laparoscopic partial jejunal resection with regional lymph node dissection was performed with combined resection of the nodule without conversion. No other tumor was detected. The resected specimen contained an irregular ulcerative tumor measuring 52 x 33 mm. Microscopic examination revealed that the mass and peritoneal nodule comprised moderately differentiated adenocarcinoma. After surgery, the patient was treated with leucovorin/bolus and infusional 5-fluorouracil/oxaliplatin for 6 months. Eleven months after surgery, a solitary peritoneal recurrence developed near the camera port site. Six months later, positron emission tomography, computer tomography, and exploratory laparotomy revealed multiple peritoneal recurrences. The patient was then treated with leucovorin/bolus and infusional 5-fluorouracil/irinotecan. Three months and 6 months later partial remission and complete response, respectively were sequentially induced. The patient is alive 3 years and 9 months after initial surgery without any tumor recurrence. To our knowledge, this is the first report to demonstrate laparoscopic surgery combined with chemotherapy regimens, which induced a successful complete response.

Magnetic compression anastomosis gastrojejunostomy: feasibility and efficacy of a novel device in a swine model.

BACKGROUND: Means of addressing technical challenges in forming gastrojejunostomy (GJ) anastomoses and maintaining their patency are sought. OBJECTIVES: Evaluation of preclinical feasibility and healing efficacy of a novel linear magnetic compression anastomosis (MCA) device to form a patent GJ versus sutured jejunal enterotomy (JE) sites in swine. SETTING: Single-center veterinary testing facility. METHODS: Feasibility of 3 prototype sizes (4, 6, and 8 cm) of a metal MCA device (MCAD) to form a patent GJ was evaluated over 6 weeks. A distal magnet was laparoscopically inserted in the jejunum, a proximal magnet was placed gastroscopically in the stomach; magnets were aligned to gradually form an anastomosis, self-detached, and be expelled. At necropsy, MCAs were assessed for patency and compared with JE tissues to evaluate wound healing. RESULTS: MCADs aligned at the GJ location without complications. In 5/6 MCAD pairs, dislodgement occurred between 7 and 26 days; expulsion 13-31 days; 1 MCAD pair was retained in the stomach. At necropsy, all pigs were healthy, gaining a mean 15.0 kg. Anastomoses were not adequately patent in 2/4 pigs receiving the 4-cm or 6-cm MCADs because their linear length was too small. But, anastomoses of both pigs receiving the 8-cm MCADs maintained full patency. Minimal inflammation and fibrosis were seen in MCA specimens versus sutured enterotomies. CONCLUSIONS: A novel linear MCA device was feasible and effectively created a patent GJ anastomosis in swine with minimal inflammation and fibrosis. The MCAD may be appropriate for clinical evaluation.