Home self-dilatation for esophageal strictures.

Esophageal strictures secondary to caustic ingestion, head and neck radiation and at the anastomosis post-esophagectomy tend to be refractory to one or several dilatations. One option for these strictures is home self-dilatation. The aim of this study was to assess the efficacy and safety of home self-dilatation for a refractory esophageal stricture. A retrospective chart review was performed of all patients from 1997 to 2009 that performed home self-dilatation for an esophageal stricture. Patients with proximal strictures without tortuosity or a shelf proximal to the stricture were selected for self-dilatation. The patients were taught self-dilatation by the surgeon and an experienced nurse, and an appropriate sized Maloney dilator was provided to the patient and returned when no longer needed. There were 16 patients (11 male and 5 female) with a median age of 60 years (range 38-78). The stricture was related to the anastomosis after esophagectomy in 12 patients, caustic injury in 3 patients and cervical chemoradiotherapy in 1 patient. Prior to initiation of self-dilatation patients had a median of four endoscopic dilatations. Self-dilatation was done with a Maloney dilator ranging in size from 45 to 60 French. The median duration of self-dilatation was 16 weeks. No patient had a perforation or complication related to self-dilatation. No patient required stenting or repetitive endoscopic dilatations because of failure of self-dilatation. Strictures recurred in two patients after cessation of self-dilatation and both responded to endoscopic dilatation followed by additional self-dilatation. Self-dilatation effectively resolves refractory esophageal strictures. It was well tolerated, and there were no complications in this series. Home self-dilatation should be considered the treatment of choice in appropriate patients with refractory esophageal strictures in the cervical esophagus.

Circular stapled pyloroplasty: a fast and effective technique for pyloric disruption during esophagectomy with gastric pull-up.

The necessity of pyloroplasty after esophagectomy and gastric pull-up is debated. Disadvantages of a standard pyloroplasty include the potential for leak, shortening of the length of the graft, and complexity when done during a minimally invasive procedure. The aim of this study is to report our experience with a novel internal pyloroplasty technique using a circular stapler (CS pyloroplasty), which is applicable for both laparoscopic and open esophagectomy. The records of all patients who underwent an esophagectomy with gastric pull-up and pyloroplasty between 2002 and 2007 were reviewed. The CS pyloroplasty was performed through a lesser curve gastrotomy with a 21-mm CS, while the standard pyloroplasty entailed a longitudinal full thickness incision through the pylorus with mucosal closure in the same direction and a Graham patch. A CS pyloroplasty was performed in 144 and a standard pyloroplasty in 133 patients. The median patient age was 66years, and the median follow-up was 17months, and was similar for both types of pyloroplasty. Routine postoperative videoesophagram was significantly more likely to show a delay in contrast transit through the pylorus after standard pyloroplasty (16% standard vs. 8% CS pyloroplasty, P= 0.03). Significantly more patients had postoperative endoscopy after standard pyloroplasty (40% standard vs. 24% CS pyloroplasty, P= 0.004), but the frequency of pyloric dilatation was similar. There were no leaks with either technique. A circular stapled pyloroplasty is as efficacious as a standard pyloroplasty after esophagectomy with gastric pull-up. Potential advantages include the ease and simplicity of the procedure along with virtually no risk of a leak and no graft shortening. The technique is amenable to both open and minimally invasive procedures.

Surgical management of submucosal esophageal cancer: extended or regional lymphadenectomy?

INTRODUCTION: Radical esophagectomy is considered the standard therapy for tumors that infiltrate the submucosa of the esophagus (T1b), as the prevalence of lymph node metastases has been reported in up to 40% of these patients. It remains unclear whether radical esophagectomy with extended lymphadenectomy is needed or whether a surgical procedure with only regional lymphadenectomy suffices. The aim of this study was to compare outcomes of patients who underwent esophagectomy for T1b cancer through a transthoracic approach with extended lymphadenectomy (TTE) with those of patients in whom transhiatal esophagectomy (THE) was performed with a regional lymph node dissection. METHODS: Patients who underwent esophagectomy for T1b cancer between 1990 and 2004 and who did not receive (neo)adjuvant therapy were included. Data were collected from prospective databases of 4 centers. In Leuven, Belgium (n = 101), and Los Angeles, CA (n = 31), patients with T1b tumors had been operated on via TTE with extended lymphadenectomy, whereas in Amsterdam (n = 43) and Rotterdam (n = 47), the Netherlands, THE with regional lymphadenectomy had been performed. RESULTS: The 2 patient groups (TTE, n = 132; THE, n = 90) were comparable with regard to age, body mass index, and ASA classification. Operative time was longer in patients who underwent TTE (390 minutes) versus THE (250 minutes) (P < 0.001). The yield of lymph nodes resected was higher in the TTE group (median: 32) versus THE (median: 10) (P < 0.001). Overall morbidity, in-hospital mortality, and length of hospital stay were comparable between both the groups. In the TTE group, 27.3% of complications were classified as major versus 14.4% in the THE group (P < 0.001); however, the reoperation rate was higher after THE (12.2%) versus TTE (3.8%) (P = 0.01). There was no difference in pathological outcomes (infiltration depth, pN stage, pM stage, positive lymph node ratio) between both groups. Overall, 5-year survival (63.4% TTE vs 69.4% THE; P = 0.55) and disease-free 5-year survival (76.9% TTE vs 78.3% THE; P = 0.65) were comparable between both the groups. In patients with N1 disease, disease-free 5-year survival was 49.8% in the TTE group versus 40.0% in the THE group (P = 0.57). CONCLUSIONS: In patients with submucosal esophageal cancer (T1b), TTE with extended lymphadenectomy and THE with regional lymphadenectomy had similar short-term outcome and long-term survival. In the selected group of T1bN1 patients, TTE may be the preferred operative technique because of a potential disease-free survival benefit; in patients with T1bN0 disease, THE with en bloc dissection of the esophagus and regional lymph nodes offers an oncologically safe and less invasive treatment.

The esophageal hiatus: what is the normal size?

BACKGROUND: A hiatal hernia is defined as the protrusion of intra-abdominal organs through a dilated esophageal hiatus. The esophageal hiatus and its function have been described extensively, but an exact anatomical determination of its normal size is lacking. It seems important to define the normal size, as crural closure is an important part of surgical treatment of gastroesophageal reflux disease (GERD) and hiatal or paraesophageal hernias. The aim of this study was to determine normal values for the size of the esophageal hiatus. METHODS: In a prospective study 50 consecutive cadaver autopsies were performed between February and May 2008. The subjects had died from several diseases not related to GERD. Size of the esophageal hiatus was measured after opening the abdominal cavity before extirpation of any organs. Distance of the cardia and gastroesophageal junction and position of the angle of His were further measured. A formula was used to calculate the hiatal surface area (HSA). Results were analyzed regarding subject height, weight, body mass index (BMI), and chest circumference. RESULTS: In all 50 cadavers (24 male/26 female) the autopsy was performed and all measurements were obtained. Mean age was 74 years (40-90 years), mean height was 1.68 m (1.39-1.83 m), mean weight was 71 kg (40-120 kg), and mean body mass index (BMI) was 25 kg/m(2) (14-40 kg/m(2)). Mean chest circumference was 101 cm (75-178 range). Mean HSA was 5.84 cm(2) (3.62-9.56 cm(2)). In all cadavers the gastroesophageal junction was intraabdominal, the mean distance to the angle of His was 3.6 cm (2.7-4.6 cm), the mean length of the right and left crura was similar at 3.6 cm (2.7-4.6 cm), and the opening segment had a mean length of 2.4 cm (1.7-4.0 cm). CONCLUSION: The mean HSA was determined in these normal subjects to be 5.84 cm(2). It was directly proportional to chest circumference and independent of height, weight, BMI, and gender.

Esophagectomy for cancer in octogenarians.

Because of changes in life expectancy, there is an increasing number of elderly patients with esophageal cancer. The aim of this study was to assess the outcome of esophagectomy for cancer in patients 80 years or older. A retrospective review was performed of the records of all patients who underwent esophagectomy for cancer from 1992 to 2007. A cardiac and pulmonary evaluation was obtained on an individual basis in the younger patients and in all octogenarians. Among 560 patients with esophagectomy for cancer, 47 patients (8%) were octogenarians. The median age of the younger group (n= 513) was 63 years (interquartile range 56-71). Octogenarians had significantly more stage III disease (49% vs 31%, P= 0.02) but received less neoadjuvant therapy than younger patients (2% vs 21%, P= 0.0004). In octogenarians, the transhiatal resection was more common than in the younger group (79% vs 36%, P < 0.0001). Weight loss prior to surgery was similar in both groups, but body mass index was significantly lower in octogenarians (25 vs 28 kg/m(2) , P= 0.0002). Major complications occurred in 26% in octogenarians and 31% in the younger group (P= 0.51). Hospital mortality was similar (9% for octogenarians vs 4% in the younger group, P= 0.13). The median postoperative hospital stay was similar at 16 days (P= 0.69). There was no difference in cancer-related survival (median survival 48.9 vs 59.3 months, P= 0.31 log-rank test). Esophagectomy can be performed safely in carefully selected octogenarians with good cardiac and pulmonary function. Patients should not be denied an esophagectomy based only on their age.

Results of a new method to stop acute bleeding from esophageal varices: implantation of a self-expanding stent.

BACKGROUND: Acute bleeding from nontreated esophageal varices is associated with a mortality rate of 30% to 50%. Various pharmacologic and interventional methods to stop acute bleeding are available. However, for 10% to 20% of patients, therapy fails to stop the bleeding. This study aimed to assess the SX-ELLA Stent Danis Set (which has a self-expanding metal stent) instead of a balloon probe for compression of esophageal varices. METHODS: Using a multidisciplinary approach, a self-expanding stent was placed in 39 patients between January 2003 and August 2007. For 34 of these patients with ongoing bleeding from esophageal varices, stent implantation was performed with the SX-ELLA Stent Danis Set, and the patients were included in this study. For all these patients, common methods failed to stop hemorrhage. With the SX-ELLA Stent Danis Set, the stent was implanted with a positioning balloon that enabled delivery without X-ray control. After implantation of the stent, its position was controlled by endoscopy and computed tomography (CT) scan. RESULTS: For all 34 patients, the implantation of the esophageal stent succeeded in stopping ongoing bleeding. No stent-related complications occurred during or after stent implantation. No bleeding recurrence was observed during the stent implantation (median time, 5 days; range 1-14 days). For all the patients, the stent could be extracted by endoscopy without any complications using an extractor. Nine patients died of hepatic failure within 30 days after the procedure. No rebleeding occurred. CONCLUSIONS: The use of a self-expanding stent to stop acute bleeding from esophageal varices is a new therapeutic method. The authors' initial experience, which involved no method-related mortality or complications, is encouraging. More data are necessary to confirm their results.

Screen height as an ergonomic factor in laparoscopic surgery.

BACKGROUND: The increasing number of routinely performed laparoscopic operations causes the surgeons' "screen work" time to rise constantly. A new ergonomic workload on the surgeons' upper spine and shoulders is created as a result of the standard screen height position on top of the laparoscopy towers. METHODS: Eight surgeons in the authors' surgical department were evaluated for the inclination/reclination angle of their cervical spine when using the laparoscopy towers in the authors' department and also at their favorable screen height. RESULTS: The laparoscopy towers used in the authors' department made 3 degrees to 14 degrees reclination of the cervical spine necessary. The interviewed surgeons preferred a position of slight inclination, with a median of 160 cm measured from the central screen height to the floor. CONCLUSION: Monitors of laparoscopy towers should be adapted to the surgeon's preferred screen height: at eye level frontally with a neutral or slight inclination of the cervical spine. The authors suggest a central screen height of 160 cm, with the monitor positioned in front of the surgeon. Newer equipment from the industry should be provided.

Five-year results of laparoscopic Toupet fundoplication as the primary surgical repair in GERD patients: is it durable?

INTRODUCTION: Most surgeons operate on gastroesophageal reflux disease (GERD) patients using the concept of "tailored approach," which depends on esophageal motility. We have abandoned this concept and performed laparoscopic Toupet fundoplication in all patients suffering from GERD, independent of their esophageal motility. METHODS: In a prospective trial we have assessed and evaluated our 5-year results of the first 100 consecutive patients treated with laparoscopic Toupet fundoplication. All patients were evaluated preoperatively by endoscopy and 24-h pH manometry. The patients were followed up clinically 1, 2, 6, 12 and 60 months postoperatively. The course of clinical DeMeester score, appearance and treatment of wrap-related side-effects as well as long-term outcome and patient satisfaction were evaluated. RESULTS: The 5-year follow-up rate was 87%. Laparoscopic Toupet fundoplication achieved a 5-year healing rate of GERD in 85%. Of all operated patients, 3.5% had to be reinstalled on a regular PPI treatment because of postoperative GERD reappearance. The median clinical DeMeester score decreased from 4.27 +/- 1.5 points preoperatively to 0.47 +/- 0.9 points 5 years postoperatively (p < 0.0005). Because of persistent postoperative dysphagia, 5% of the patients required endoscopic dilatation therapy. Persistent postoperative gas-bloat syndrome occurred in 1.1%. Wrap dislocation was identified in 3.4% of patients. Reoperation rate was 5%. Total morbidity rate was 19.5% and operative related mortality rate was 0%. Overall, 96.6% of patients were pleased with their outcome at late follow-up, and 95.4% of patients stated they would consider undergoing laparoscopic fundoplication again if necessary. CONCLUSION: Our long-term results showing a low recurrence and morbidity rate of laparoscopic Toupet fundoplication encourage us to continue to perform this procedure as the primary surgical repair in all GERD patients, independent of their esophageal motility. Laparoscopic Toupet fundoplication has proven to be a safe and successful therapeutic option in GERD patients.

A 6-year experience with the Swedish adjustable gastric band Prospective long-term audit of laparoscopic gastric banding.

BACKGROUND: In morbid obesity conservative therapy often fails to reduce overweight permanently. As a consequence, several bariatric surgical procedures have been developed to achieve permanent excess weight loss. Among these, the laparoscopic restrictive procedures seem to be the least invasive. The aim of this prospective study was to assess and analyze the effects, complications, and outcomes after the implantation of the Swedish adjustable gastric band (SAGB) in long-term follow-up. METHODS: All consecutive patients with implantation of a SAGB between August 1996 and August 2002 were prospectively investigated. The placement of the SAGB was done by laparoscopy in all cases. Success was rated by the reduction of body mass index (BMI) excess weight loss (EWL), and reduction of comorbidities. "Nonresponders" to SAGB were defined as <30% EWL after a 3-year follow-up. Band-related complications were recorded and classified. Patient's outcome was assessed after 6 months and subsequently each year postoperatively. RESULTS: A total of 190 patients received a SAGB, 97% of whom could be followed up with a mean follow-up period of 39.4 months (duration of follow-up, 6-72). During follow-up, a significant reduction or improvement of BMI, EWL, and comorbidities were found. Nineteen percent of patients were identified as nonresponders. Early intraoperative and postoperative complications related to SAGB were one perforation of the gastric fundus (0.5%), one conversion (0.5%), one bleeding (0.5%), and two band infections (1.1%). The SAGB-related complications encountered during long-term follow-up were three port problems (1.6%), four band migrations (2.1%), five slipping/pouch dilatations (2.6%), and two band leakages (1.1%). All intra- and postoperative SAGB-related complications accounted for a total morbidity of 10.5%. Operative mortality was 0%. The overall reoperation rate was 8.5%. CONCLUSIONS: In long-term follow-up, SAGB is safe and effective. Our results demonstrate a significant EWL of 50% during the first 24 months. However, patient selection has to be improved to reduce the nonresponder rate. SAGB leads to a significant reduction of obesity-related comorbidities. SAGB is an attractive alternative in the surgical treatment of morbid obesity.

A new technique for measurement of pharyngeal pH: normal values and discriminating pH threshold.

INTRODUCTION: Identifying gastroesophageal reflux disease as the cause of respiratory and laryngeal complaints is difficult and depends largely on the measurements of increased acid exposure in the upper esophagus or ideally the pharynx. The current method of measuring pharyngeal pH environment is inaccurate and problematic due to artifacts. A newly designed pharyngeal pH probe to avoid these artifacts has been introduced. The aim of this study was to use this probe to measure the pharyngeal pH environment in normal subjects and establish pH thresholds to identify abnormality. METHODS: Asymptomatic volunteers were studied to define the normal pharyngeal pH environment. All subjects underwent esophagram, esophageal manometry, upper and lower esophageal pH monitoring with a dual-channel pH catheter and pharyngeal pH monitoring with the new probe. Analyses were performed at 0.5 pH intervals between pH 4 and 6.5 to identify the best discriminating pH threshold and calculate a composite pH score to identify an abnormal pH environment. RESULTS: The study population consisted of 55 normal subjects. The pattern of pharyngeal pH environment was significantly different in the upright and supine periods and required different thresholds. The calculated discriminatory pH threshold was 5.5 for upright and 5.0 for supine periods. The 95th percentile values for the composite score were 9.4 for upright and 6.8 for supine. CONCLUSION: A new pharyngeal pH probe which detects aerosolized and liquid acid overcomes the artifacts that occur in measuring pharyngeal pH with existing catheters. Discriminating pH thresholds were selected and normal values defined to identify patients with an abnormal pharyngeal pH environment.

Elliptic-mode cavity for diode-pumped lasers.

A novel laser resonator capable of producing a strongly elliptic TEM(00) mode in the gain medium is analyzed. Careful design results in an axially symmetric output beam, while the squeezed mode volume in the active medium allows an optimum exploitation of the inversion generated by end pumping the laser with a high-power laser-diode array. When a single array is used, the pump threshold can be typically reduced by an order of magnitude as compared with conventional (circular-mode) end-pumped systems without compromising any other laser characteristics. The combination of the presented cavity design with geometric multiplexing of diode arrays provides an efficient means for scaling end-pumped lasers to high powers.