Endoluminal Vacuum Therapy: How I Do It.

Perforations and leaks of the gastrointestinal tract are difficult to manage and are associated with high morbidity and mortality. Recently, endoscopic approaches have been applied with varying degrees of success. Most recently, the use of endoluminal vacuum therapy has been used with high success rates in decreasing both morbidity and mortality. Under an IRB-approved prospective registry that we started in July 2013, we have been using endoluminal vacuum therapy to treat a variety of leaks throughout the GI tract. The procedure uses an endosponge connected to a nasogastric tube that is endoscopically guided into a fistula cavity in order to facilitate healing, obtain source control, and aid in reperfusion of the adjacent tissue with debridement. Endoluminal vacuum therapy has been used on all patients in the registry. Overall success rate for healing the leak or fistula is 95% in the esophagus, 83% in the stomach, 100% in the small bowel, and 60% of colorectal cases. The purpose of this report is to review the history of endoluminal wound vacuum therapy, identify appropriate patient selection criteria, and highlight "pearls" of the procedure. This article is written in the context of our own clinical experience, with a primary focus on a "How I Do It" technical description.

Robotic Curriculum Enhances Minimally Invasive General Surgery Residents' Education.

OBJECTIVE: Resident education is evolving as more cases move from open to minimally invasive. Many programs struggle to incorporate minimally invasive surgery education due to increased operative time and higher cost when residents participate. The aim of this paper is to examine if the implementation of a robotics curriculum enhances minimally invasive surgical training. DESIGN: A retrospective review of all ventral and inguinal hernia cases performed from March 2013 to November 2017 was conducted to determine operative technique utilized (open, laparoscopic, or robotic) and resident involvement. The study cohorts surrounded the introduction of a robotic curriculum in July 2014, and the time frames examined were labeled as Before-robotic, After-robotic, and re-visited examination was done labeled Long-term. SETTING: The study was performed at a large quaternary care referral center. PARTICIPANTS: The participants were all patients who underwent ventral and inguinal hernia repairs on the general surgery, transplant, or colorectal service. RESULTS: Before-robotic had 739 hernia cases performed: 642 (87%) open, 93 (13%) laparoscopic, and 4 (0.5%) robotic. After-robotic had 682 hernia cases performed: 529 (78%) open, 54 (8%) laparoscopic, and 99 (15%) robotic. Long-term had 792 hernia cases performed: 603 (76%) open, 25 (3%) laparoscopic, and 164 (21%) robotic. The general trend was towards an institutional decrease in open cases and an increase in robotic hernia cases. Resident participation in the robotics cases across all levels increased after the implementation of the robotic curriculum. CONCLUSIONS: Implementation of a robotic curriculum can enhance minimally invasive surgical training experience for general surgery resident education.

Endoscopic Removal of Noneroded Nonadjustable Gastric Bands Using Induced Mucosal Erosion With a Stent, and Review of the Literature.

BACKGROUND: Laparoscopic removal of noneroded nonadjustable gastric bands (NAGBs) may lead to major life-threatening complications. A minimally invasive approach involving endoscopic removal by induced mucosal erosion with a stent (IMES) has been used in a few publications to remove NAGBs. OBJECTIVE: To examine a minimally invasive endoscopic approach to removal of a NAGB. SETTING: A large tertiary/quaternary referral hospital. METHODS: We report 4 patients that underwent IMES at our institution and present a literature review of published cases. The procedure includes using an endoscopically placed fully covered stent through the NAGB stricture to cause erosion of the mucosa where the stent is putting direct pressure. After a predetermined length of time, the stent is removed with the NAGB and without a laparoscopic or open procedure. Primary endpoint for our cohort was successful removal to the NAGB with IMES. Secondary endpoints included interval of time to retrieval of the stent, complications from IMES, presenting symptoms, and type of NAGB. These endpoints were then compared with previous publications indicating the use of IMES. RESULTS: Three of 4 patients were female with a mean age of 64.5 years. All patients had the NAGB successfully removed with IMES. The mean time for NAGB and stent removal after insertion was 17.5 days. No major complications were noted. Two patients had post-IMES strictures and were managed by balloon dilation. CONCLUSION: Endoscopic removal of NAGBs is a safe and feasible procedure for NAGB removal and can be used in place of laparoscopic surgery.

Primary and Rescue Endoluminal Vacuum Therapy in the Management of Esophageal Perforations and Leaks.

BACKGROUND: To investigate the efficacy of primary and rescue endoluminal vacuum (EVAC) therapy in the treatment of esophageal perforations and leaks. METHODS: We conducted a retrospective review of a prospectively gathered, Institutional Review Board (IRB) approved database of EVAC therapy patients at our center from July 2013 to September 2016. RESULTS: In all, 13 patients were treated for esophageal perforations or leaks. Etiologies included iatrogenic injury (n = 8), anastomotic leak (n = 2), Boerhaave syndrome (n = 1), and bronchoesophageal fistula (n = 2). In total, 10 patients underwent primary treatment and three were treated with rescue therapy. Mean Perforation Severity Scores (PSSs) in the primary and rescue treatment groups were 7 and 10, respectively. Average defect size was 2.4 (range: 0.5-6) cm. The rescue group had a shorter mean time to defect closure (25 vs. 33 days). In all, 12 of 13 defects healed. One death occurred following the implementation of comfort care. One therapy-specific complication occurred. Hospital length of stay (LOS) was longer in the rescue group (72 vs. 53 days); however, the intensive care unit (ICU) duration was similar between groups. Totally, 10 patients (83%) resumed an oral diet after successful defect closure. CONCLUSION: Utilized as either a primary or rescue therapy, EVAC therapy appears to be beneficial in the management of esophageal perforations or leaks.

Endolumenal Vacuum Therapy and Fistulojejunostomy in the Management of Sleeve Gastrectomy Staple Line Leaks.

Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric surgery performed for morbid obesity. Leaks of the vertical staple line can occur in up to 7% of cases and are difficult to manage. Endolumenal vacuum (EVAC) therapy and fistulojejunostomy (FJ) have separate documented uses to heal these complicated leaks. We aim to show the benefit of using EVAC with FJ in the treatment of LSG staple line leaks. The patient presented with an LSG chronic leak. EVAC therapy was initiated but failed to close the fistula after 101 days. EVAC therapy was abandoned, and FJ was performed to resolve the leak. Postoperatively, no leak was encountered requiring any additional procedures. Based on our findings, we conclude that EVAC therapy facilitates in resolving leaks that restore gastrointestinal continuity and maintain source control. It promotes healing and causes reperfusion of ischemic tissue and fistula cavity debridement.

Comparison of outcomes of laparoscopic Heller myotomy versus per-oral endoscopic myotomy for management of achalasia.

Achalasia is a rare disorder that has several treatment options. The gold standard of treatment is a surgical myotomy called a laparoscopic Heller myotomy (LHM). More recently, an endoscopic myotomy has become an option as well, called per-oral endoscopic myotomy (POEM). An achalasia registry was queried for patients undergoing either LHM or POEM at Baylor University Medical Center at Dallas. Patient demographics, preoperative and postoperative data points, and Eckardt scores were collected. The patients were further stratified into their follow-up intervals, immediate postoperative and long-term follow-up, to assess surgical success. A subset analysis was done for success of treatment for patients who had redo surgery versus those undergoing the procedure for the first time. There were 12 patients in the POEM group and 11 patients in the LHM group. Both groups demonstrated mean lower esophageal sphincter pressures with failure to relax. Procedure length and hospital length of stay were similar between the two groups. There were three adverse events in each group, but none altered the patient's postoperative clinical course. Eckardt scores, used to assess success of the surgery, were 82% for POEM patients and 66% for LHM patients after 6 months. The outcomes for POEM and LHM in our early experience are similar to those reported in the literature for high-volume centers managing achalasia.