Endoscopic basilic vein transposition for hemodialysis access.

BACKGROUND: Hemodialysis access by autogenous arteriovenous fistulas (AVFs) is generally recommended due to lower mortality, morbidity, and cost vs graft and catheter use. Many dialysis patients lack the common superficial veins used for standard AVF options and require transposition of a deep vein for autogenous dialysis access through a long open incision (open/AVF-T). These operations may require prolonged time for healing, thus extending catheter-based dialysis. We report our experience with minimally invasive techniques for creating AVF-Ts using an endoscopic procedure (endo/AVF-T). METHODS: We reviewed our vascular access database of consecutive access operations to identify consecutive patients with endo/AVF-Ts. For comparison, we also reviewed the immediate preceding traditional open/AVF-T operations that we previously reported. We evaluated demographics, time to access use, and primary, assisted, and cumulative patency. RESULTS: We identified 100 consecutive endo/AVF-T operations attempted, and 98 were technically successful. The analysis excluded two conversions to successful open/AVF-T. The mean age of the 98 patients in the endo/AVF-T study group was 60 years (range, 22-94 years), 59 (60.2%) were women, 48 (49.0%) were diabetic, 20 (20.4%) were obese, and 52 (53.1%) had had previous access surgery. Mean time to initial use of the access for endo/AVF-Ts was 6 weeks for primary and 12 weeks for staged transpositions. Mean follow-up was 14 months (range, 1-30 months). The 12- and 24-month cumulative patencies were 95.5% and 88.6%. The 78 traditional open/AVF-T operations from our previous report were reviewed for comparison. The mean age was 62 years (range, 18-83 years), 57 (73.1%) were women, 44 (56.4%) were diabetic, 15 (19.2%) were obese, and 46 (59.0%) had previous access surgery. Mean time to initial use of the access for open/AVF-Ts was 8 weeks for primary and 16 weeks for staged operations. Mean follow-up was 18 months (range, 3-48 months). The 12- and 24-month cumulative patencies were 96.0 and 88.9%. No grafts were used in any patient during the study period. CONCLUSION: Time to access use was less with endoscopic AVF-T (P < .01) for both primary and staged operations. Primary, assisted, and cumulative patency rates were the same for open and technically successful endoscopic transpositions. Endoscopic AVF-Ts offer a viable alternative to open AVF-Ts.

Laparoscopic Heller myotomy for achalasia.

BACKGROUND: Achalasia is an uncommon illness affecting 1 per 100,000 patients yearly. There is evidence to suggest viral, autoimmune, and hereditary etiologies. There are many treatment options available including medications, botulinum toxin injection, pneumatic dilation, and surgical myotomy. METHODS: We present a retrospective review of patients undergoing laparoscopic-modified Heller myotomy at a large referral and surgical training center. RESULTS: There were 36 patients identified. Thirty patients had undergone prior treatment with botulinum toxin injection, pneumatic dilation, previous Heller myotomy, or esophageal stenting. Immediate complications included mucosal perforation (2), spleen injury (1), and trocar-site infection (1). There were no postoperative esophageal leaks. Three patients suffered reflux requiring the daily use of a proton pump inhibitor 9 months after surgery. Three patients suffered recurrent dysphagia. CONCLUSIONS: Presently, there are little data to suggest an ideal management strategy in patients with achalasia. Our patient population consists predominantly of failures of other treatment methods submitted for laparoscopic myotomy. Our data suggest that laparoscopic Heller myotomy can be safely undertaken in this population, without a higher than expected rate of recurrent symptoms or reflux.

Techniques for repair of gastric prolapse after laparoscopic gastric banding.

Laparoscopic gastric banding is a valuable surgical option for treating morbidly obese patients. Its operative technique is continually being refined. Since its inception, many changes in technique have helped to reduce the complication rate. Currently, the major complications are obstruction, erosion, and band slippage. Band slippage requires surgical correction. Since each band costs approximately 3000 dollars, surgeons should attempt to preserve the band when facing patients with this complication. This paper discusses the techniques for the reduction of band slippage.

Peritoneal dialysis catheters: laparoscopic versus traditional placement techniques and outcomes.

BACKGROUND: Peritoneal dialysis is used for renal replacement therapy in over 25,000 patients in the United States. Some authors have recommended laparoscopic guidance for peritoneal dialysis catheter (PDC) placement, although consensus statements have not favored a specific technique. This study reviews outcomes in patients in whom placement was performed by the traditional "blind" technique (B-PDC) versus the laparoscopic technique (L-PDC). METHODS: Records were retrospectively reviewed of 25 consecutive PDC patients in each of 3 university-affiliated tertiary medical center hospitals. Data for PDCs placed by B-PDC (n = 30) or L-PDC (n = 45) technique were reviewed and the outcomes compared. RESULTS: L-PDCs offered 97.8% immediate functional success as opposed to 80% with B-PDC placement (P = .014). In addition, laparoscopic placement of peritoneal dialysis catheters had a lower incidence of PDC revision or replacement (P = .035). CONCLUSION: L-PDCs were found to have a higher immediate functional success rate than B-PDCs and a lower incidence of catheter revision or replacement.