Calculation of esophagogastric junction vector volume using three-dimensional high-resolution manometry.

Lower esophageal sphincter vector volume (V-V) was developed in the late 1980s by Bombeck, as a quantification of sphincter integrity used to select reflux patients with a defective valve who may benefit from surgery. Its calculation required motorized pull-through of an 8-lumen water perfused manometry catheter with subsequent computerized reconstruction of sphincter morphology. Recently, a three-dimensional high-resolution manometry (3D-HRM) assembly (Given Imaging, Duluth, GA, USA) has been developed with the potential to assess real-time V-V. The aim of this study was to assess the feasibility of the calculation of V-V using the 3D-HRM assembly and to compare measures of its value using real-time 3D-HRM to simulated analogous measures. Eight asymptomatic controls (4F, ages 26-49) were studied in a supine position with a solid-state 3D-HRM assembly positioned across the esophagogastric junction (EGJ). The 9-cm 3D segment comprised 12 rings of 8 radially dispersed pressure sensors, each 2.5 mm long and spaced 7.5 mm apart on center. Recordings were done during normal respiration: (i) with the 3D-HRM segment in a stationary position across the EGJ; and (ii) during a station pull-through of the 3D-HRM segment withdrawing it across the EGJ at 5-mm increments with each position held for 30 seconds. EGJ cross-sectional vector areas (CSVAs) were computed using the irregular polygon area formula: [Formula in text], and n = 8 radial sensors. V-V was computed as the sum of CSVAs at inspiration and end-expiration by three methods: real-time 3D-HRM, three-station composite, and single-sensor ring measurements. There were no statistic differences among the methods, and all methods showed significant differences between inspiration and expiration. Calculation of real-time V-V is feasible using the 3D-HRM. Moreover, the results of this study highlighted the potential primary role of the diaphragmatic hiatus in the pathophysiology of gastroesophageal reflux disease and the underrecognized but crucial role of the crural repair during the antireflux surgery.

Histologic results 1 year after bioprosthetic repair of paraesophageal hernia in a canine model.

BACKGROUND: The use of prosthetic materials for the repair of paraesophageal hiatal hernia (PEH) may lead to esophageal stricture and perforation. High recurrence rates after primary repair have led surgeons to explore other options, including various bioprostheses. However, the long-term effects of these newer materials when placed at the esophageal hiatus are unknown. This study assessed the anatomic and histologic characteristics 1 year after PEH repair using a U-shaped configuration of commercially available small intestinal submucosa (SIS) mesh in a canine model. METHODS: Six dogs underwent laparoscopic PEH repair with SIS mesh 4 weeks after thoracoscopic creation of PEH. When the six dogs were sacrificed 12 months later, endoscopy and barium x-ray were performed, and biopsies of the esophagus and crura were obtained. RESULTS: The mean weight of the dogs 1 year after surgery was identical to their entry weight. No dog had gross dysphagia, evidence of esophageal stricture, or reherniation. At sacrifice, the biomaterial was not identifiable grossly. Biopsies of the hiatal region showed fibrosis as well as muscle fiber proliferation and regeneration. No dog had erosion of the mesh into the esophagus. CONCLUSIONS: This reproducible canine model of PEH formation and repair did not result in erosion of SIS mesh into the esophagus or in stricture formation. Native muscle ingrowth was noted 1 year after placement of the biomaterial. According to the findings, SIS may provide a scaffold for ingrowth of crural muscle and a durable repair of PEH over the long term.

NIS vs SAGES: a comparison of national and voluntary databases.

BACKGROUND: Surgical outcomes are increasingly examined in an effort to improve quality and reduce medical error. The Nationwide Inpatient Sample (NIS) is a retrospective, claims-derived and population-based database and the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Outcomes Project is a prospective, voluntary and specialty surgeon database. We hypothesized that these two sources of outcome data would differ in regard to a single, commonly performed procedure. METHODS: Both the NIS, a national sample of all nonfederal hospital discharges, and the gastroesophageal reflux disease log of the SAGES Outcomes Project were queried for all fundoplications performed between 1999 and 2001 using either ICD-9 procedure code 44.66 or CPT codes 43280 or 43324. Patients with an emergency admission, age <17 years, and/or diagnoses for either esophageal cancer or achalasia were excluded. Both demographic and outcome variables were compared by either t-test or chi-square analysis, with a p value of <0.05 as significant. RESULTS: Both data sets were comparable for age and gender; however, the SAGES group had a higher rate of teaching hospital affiliation (71 vs 48%, p < 0.001). SAGES fundoplications had a consistently higher rate of comorbidities, including Barrett's esophagus (2.3 vs 1.1%, p = 0.005). The NIS fundoplications had a clear trend toward more associated procedures, including cholecystectomy (7.2 vs 2%, p < 0.001). Complication rates for the NIS data set were higher, including pulmonary complications (1.7 vs 0.5%, p = 0.03). No statistically significant differences existed between the two data sets for either length of stay or mortality. CONCLUSIONS: The two databases indicate that fundoplication is an operation with low morbidity and mortality. The SAGES Outcomes Project demonstrated that participating surgeons had a higher affiliation with teaching hospitals, higher reporting of comorbidity, and lower associated procedures than the NIS. Despite having more comorbidity and technical difficulty, patients from the SAGES Outcomes Project had equivalent or lower complication rates.

Experience with laparoscopic gastric resection: results and outcomes for 37 cases.

BACKGROUND: This study aimed to review the authors' technique, results, and outcomes for laparoscopic gastric wedge and segmental resections in patients with benign gastric diseases. METHODS: A retrospective clinical chart review was performed for all the patients who underwent laparoscopic gastric resection at the Washington University Medical Center from 1997 through March 2004. The surgical approach, operative results, complications, and subsequent clinical course were analyzed. Data are expressed as mean +/- standard deviation. RESULTS: Laparoscopic gastric resection was attempted in 37 cases involving 21 women and 16 men with a mean age of 61 +/- 13 years. The indications for surgery included suspected gastric stromal tumor (GIST) or carcinoid (n = 22), other benign gastric lesions (n = 6), benign gastric outlet obstruction (n = 4), and nonhealing peptic ulcer (n = 5). Segmental resection using gastroenteric anastomosis, with or without vagotomy, was performed in 14 patients, wedge resection in 22 patients, and laparoscopic enucleation in 1 patient. Resection was totally laparoscopic in 25 cases and laparoscopically assisted (with an accessory incision) in 12 cases. The mean operative time was 165 +/- 58 min, and the blood loss was 84 +/- 77 ml. Two patients (5.4%) underwent conversion to open resection. Intraoperative gastroscopy was performed in 16 cases (44%) as an aid to the resection. Regular diet was resumed at a mean of 3.0 +/- 1.7 days, and the mean length of hospital stay was 3.9 +/- 2.1 days. Four patients (10.8%) experienced major complications including subphrenic abscess (n = 1), pneumonia with respiratory failure (n = 1), splenic vein injury requiring splenectomy (n = 1), and gastric outlet obstruction (n = 1) that required reoperation 1 year later. Minor complications included intraabdominal fluid collection (n = 1), postoperative gastroparesis (n = 1), urinary retention (n = 1), and incisional hernia (n = 1). CONCLUSIONS: Laparoscopic gastric resections can be performed safely in patients with a variety of benign gastric disorders. The use of an accessory incision for reanastomosis and specimen extraction facilitates the procedure in difficult cases.

Laparoscopic incisional hernia repair in a porcine model: what do transfixion sutures add?

BACKGROUND: The aim of this study was to evaluate the need for transfixion sutures during laparoscopic ventral hernia repair with mesh. METHODS: Incisional hernias were created in 14 Yucatan mini-pigs. Animals were randomized to undergo laparoscopic hernia repair either with spiral tacks alone (Tacks) or with tacks and 4 Prolene transfixion sutures (Sutured) using Composix E/X mesh (Davol Inc.). At 4 weeks, exploratory laparoscopy was performed to assess the repair and score adhesions. The abdominal wall was harvested for tensile strength analysis and histologic evaluation. Continuous variables were compared using a two-tailed nonpaired t-test. Results are presented as mean +/- standard deviation. RESULTS: The mean hernia size was 8.5 +/- 0.5 cm by 5.5 +/- 0.7 cm, with no difference between groups. The operative time was significantly longer ( p = 0.006) for the Sutured group (62.1 +/- 16.8 min) than for the Tacks group (32.3 +/- 7.0 min). The number of tacks per repair was equivalent between groups. At necropsy, the mesh in all cases was well incorporated, reperitonealized, and without evidence of migration. No hernias recurred. However, the Sutured group had a significantly ( p < or = 0.05) higher adhesion score (5.4 +/- 3.3) than the Tacks group (2.0 +/- 2.7). The tensile strength of the repair zone was no different between groups (Sutured 4.8 +/- 1.5 N/cm, Tacks 3.8 +/- 1.4 N/cm). On histologic examination, the ratio of inflammatory cells to fibroblasts was similar between groups (Sutured 0.2 +/- 0.6, Tacks 0.2 +/- 0.3). Only 82% of tacks in each group penetrated the fascia, and the depth of tack penetration was similar between groups (Sutured 3.7 +/- 0.3 mm, Tacks 3.9 +/- 0.4 mm). CONCLUSIONS: In a porcine model, the use of transfixion sutures was associated with longer operative times and more adhesions, without improvement in tensile strength or mesh incorporation. A human clinical trial is needed to determine the optimal method of securing abdominal wall mesh.

Results of laparoscopic Heller-Toupet operation for achalasia.

BACKGROUND: Laparoscopic myotomy has become the preferred treatment for achalasia. Controversy persists on the need for fundoplication and/or its type; when used, most series have utilized the Dor fundoplication. We report a large series of laparoscopic Heller-Toupet procedures. METHODS: All patients operated for achalasia were entered into a prospective database. Pre and postoperative esophageal symptoms, satisfaction scores, and SF-36 variables were compared. Surgical failures were defined as recurrent or persistent dysphagia leading to secondary treatment. Data are expressed as mean +/- S.D. RESULTS: One hundred consecutive cases were analyzed (61 men, 39 women, age 47 +/- 17 yr). Heller-Toupet was performed in 94, whereas six patients had a Dor fundoplication because of mucosal perforation (three) or technical difficulties performing a posterior wrap (three). Operative time was 148 +/- 21 min. There were 13 intraoperative adverse events managed laparoscopically, and no conversions. Minor postoperative complications were noted in two cases, whereas there were no major complications or deaths. Mean hospital stay was 1.2 +/- 0.5 days, (range 1-4). Follow-up was complete in 92% at 26 +/- 17 months. Failures leading to further treatment occurred in 4%. All symptom scores were significantly improved (p < 0.0001). Solid dysphagia score went from 6.4 to 1.0 postoperatively; regurgitation score went from 4.5 to 0.2 (combined frequency and severity, range 0-8). Postoperative global esophageal symptoms scale revealed improvement in 97%, and all domains of the SF-36 were improved. CONCLUSIONS: Although the best surgical approach to achalasia is yet to be determined, laparoscopic Heller-Toupet operation in experienced hands is a safe and effective procedure with low rates of morbidity and failure and high patient satisfaction.

Obesity does not adversely affect the outcome of laparoscopic antireflux surgery (LARS).

BACKGROUND: Because it has been suggested that obesity adversely affects the outcome of LARS, it is unclear how surgeons should counsel obese patients referred for antireflux surgery. METHODS: A prospective database of patients undergoing LARS from 1992 to 2001 was used to compare obese and nonobese patients. Patients were surveyed preoperatively and annually thereafter. Questionnaires were completed regarding global symptoms and overall satisfaction. RESULTS: Of the 505 patients, the body mass index (BMI) was <25 (normal) in 16%, 25-29 (overweight) in 42%, and >30 (obese) in 42%. Although the operative time was longer in the obese group than in the normal weight group (137 +/- 55 min vs 115 +/- 42 min, p = 0.003), the time to discharge and rate of complications did not differ. At a mean follow-up of 35 +/- 25 months, there were no differences in symptoms, overall improvement, or patient satisfaction. Further, the rates of anatomic failure were similar among the obese, overweight, and normal weight groups. CONCLUSIONS: Although the operative time is longer in the obese, complication and anatomic failure rates are similar to those in the nonobese at long-term follow-up. Obese patients have equivalent symptom relief and are equally satisfied postoperatively. Therefore, obesity should not be a contraindication to LARS.

Influence of spastic motor disorders of the esophageal body on outcomes from laparoscopic antireflux surgery.

BACKGROUND: The clinical outcomes of laparoscopic antireflux surgery (LARS) in patients with the spectrum of nonspecific spastic esophageal motor disorders (NSSDs) are not known. METHODS: From a prospective database of patients undergoing LARS between 1997 and 2000, those with preoperative manometry at our institution and follow-up at ?6 months were identified. RESULTS: Of the 121 patients, 35 had NSSDs. There were no differences in symptoms between groups preoperatively, but in the immediate postoperative period NSSD patients had more symptoms than nonspastic patients. At 18-month mean follow-up, NSSD patients reported significantly more heartburn (22% vs 7%), waterbrash (14% vs 4%), and medication usage (17% vs 5%) than nonspastic patients (p <0.05 for each). Despite this difference, nearly all patients reported subjective improvement postoperatively, and the degree of improvement was similar between groups. CONCLUSIONS: Patients with NSSDs are more likely to have esophageal symptoms following LARS than subjects without these abnormalities. However, these patients still experience significant improvement in preoperative symptoms.

Comparison of laparoscopic choledochotomy closure techniques.

BACKGROUND: Laparoscopic common bile duct exploration (CBDE) has traditionally been accompanied by T-tube drainage. However, other methods of choledochotomy closures have been reported. This study compared three laparoscopic methods of choledochotomy closure in a prospective, randomized fashion to determine which method should be the preferred technique. METHODS: In this porcine model, 24 animals initially underwent laparoscopic common bile duct (CBD) clipping to simulate an obstruction. Two days later, the animals underwent laparoscopic clip removal and simulated CBDE through a 1.5-cm choledochotomy. The animals were then randomized to one of three groups: primary choledochotomy closure (group I), antegrade CBD stenting with primary closure (group II), or T-tube placement (group III). To assess for CBD stenoses and leaks, the animals were killed 2 months postoperatively, at which time a cholangiogram was performed and the bile duct harvested. The ratio of proximal CBD to choledochotomy site was assessed radiographically and histologically. RESULTS: The operative time was significantly longer in group III (200 +/- 13 min, p < 0.05) than in group I (141 +/- 17 min) and group II (154 +/- 16 min). The ratio of the proximal CBD diameter to the choledochotomy site diameter by cholangiogram was 2.1:1.0 in group I, to 1.2:1.0 in group II, and 1.1:1.0 in group III (p < 0.01). The ratio of the proximal CBD intraluminal area to the choledochotomy site intraluminal area was 2.1:1.0 in group I compared to 1.1:1.0 in groups II and III (p < 0.01). None of the animals developed jaundice or sepsis. CONCLUSION: Significant stenoses were present at the choledochotomy site in the primary closure group, and T-tube placement resulted in prolonged operative times. We conclude that laparoscopic antegrade CBD stenting with primary closure of the choledochotomy site is the preferred technique after choledochotomy in an animal model. Further assessment in a clinical trial is warranted.

Symptomatic outcomes of laparoscopic antireflux surgery in patients eligible for endoluminal therapies.

BACKGROUND: This study compared clinical outcomes after laparoscopic antireflux surgery (LARS) in patients with gastroesophageal reflux disease (GERD) who would be eligible for endoluminal therapies (ET) with those in patients who would be excluded from ET. METHODS: From 1995 to the present, 459 patients who underwent LARS were analyzed prospectively. Of these, 117 patients (25%) without preoperative dysphagia, stricture, esophagitis worse than grade 2 or hiatal hernia larger than 2 cm were considered potential candidates for ET (group 1). By these criteria, 342 patients (75%) were not eligible for ET (group 2). Medication use and GERD symptoms were evaluated and compared between the two groups. RESULTS: Perioperative outcomes including duration of operation, morbidity, length of hospital stay and return to work were similar in the two groups. Although LARS significantly reduced medication use and GERD symptoms in both groups during a mean follow-up period longer than 2 years, there were no outcome differences between groups 1 and 2. The reported improvement in esophageal symptoms and overall satisfaction was 90% or more in both groups. CONCLUSIONS: The findings show that LARS is an effective treatment option in patients with GERD whether they are candidates for ET or not. In patients with uncomplicated GERD who currently meet inclusion criteria for ET, LARS provides excellent symptom relief and marked reduction in medication use during a mean follow-up period longer than 2 years.

Laparoscopic intracorporeal ultrasound versus fluoroscopic intraoperative cholangiography: after the learning curve.

BACKGROUND: The purpose of this study was to compare the results of laparoscopic intracorporeal ultrasound (LICU) to those of fluoroscopic intraoperative cholangiography (FIOC) during laparoscopic cholecystectomy (LC) after the initial learning curve for LICU. METHODS: Data were prospectively collected on patients undergoing LC. A consecutive series of 394 LICU patients was compared to a consecutive series of 400 FIOC patients when each imaging procedure was preferentially performed. Patients during the transition period, including the first 100 LICU patients, were excluded. RESULTS: Demographics and preoperative diagnoses were similar in the two groups. Excluding those who were converted to open cholecystectomy and those in whom an imaging exam was not attempted, FIOC was successful in 361 of 374 (97%) patients and LICU was successful in 377 of 380 (99%) patients (p < 0.03). The mean times (+/-SEM) to complete FIOC and LICU were 16.0 (+/-0.5) min and 5.1 (+/-0.1) min (p < 0.0001), respectively, Choledocholithiasis was detected in 25 patients (7%) undergoing FIOC and in 39 patients (10%) undergoing LICU (p = 0.1). During LICU the common bile duct was visualized in continuity from the cystic duct to ampulla in 90% of cases. The common bile duct could not be completely visualized in continuity at the middle or distal portion of the common bile duct in 5% and 6% of LICU cases, respectively. One LICU patient (0.3%) with an incompletely visualized duct had a suspected stone confirmed by postoperative endoscopic retrograde cholangiopancreaticography (ERCP). One patient with negative FIOC (0.3%) had a retained stone treated by postoperative ERCP. CONCLUSION: LICU is safe and accurate, and it permits a more rapid evaluation of bile duct stones than FIOC during laparoscopic cholecystectomy. The false-negative rate of both imaging techniques is less than 1%.

Assessment of fatigue, monitor placement, and surgical experience during simulated laparoscopic surgery.

BACKGROUND: Laparoscopic surgery requires the surgeon to assume atypical postures for extended periods of time, potentially leading to fatigue and chronic injury. This study assessed the level of muscle activity and compared the effects of fatigue, monitor placement, and surgical experience during simulated laparoscopic surgery. METHODS: Four attending and four resident surgeons repeated a series of four tasks with a View site and a standard operating room monitor. Electromyography (EMG) activity and muscular discomfort scores were obtained before and after a "fatigue session." Two variables, the EMG amplitudes and discomfort scores, were analyzed. RESULTS: The EMG amplitudes generally exceed the recommended threshold limits of acceptable muscular load. EMG data and discomfort scores demonstrated a fatigue response in several muscle groups. Minimal differences between the two monitor positions were seen. Overall, the EMG data and discomfort scores showed less muscle activity and discomfort in the attending surgeons. CONCLUSION: Laparoscopic surgery required a relatively high muscular load, putting surgeons at risk for fatigue and injury. Altering the monitor placement did not reduce the surgeon's risk of fatigue. Experience slightly reduced the level of fatigue, but not enough to reduce the surgeon's risk category.

Laparoscopic excision of mesenteric cysts: a report of two cases.

The authors report two cases of mesenteric cysts that were excised laparoscopically. Resection was accomplished with standard minimally invasive techniques and use of an ultrasonic scalpel. Both patients recovered promptly with minimal morbidity and returned to full activity within a short time. This reveals the suitability of minimally invasive surgery for this particular disease process.

Prospective, randomized trial of bipolar electrosurgery vs ultrasonic coagulation for division of short gastric vessels during laparoscopic Nissen fundoplication.

BACKGROUND: Division of the short gastric vessels (SGV) during laparoscopic Nissen fundoplication (LNF) may improve outcome. Several techniques are available for SGV division. The aim of this study was to compare in a prospective randomized trial bipolar electrocautery with cutting blade versus ultrasonic coagulation of the SGV during LNF. METHODS: In all, 86 consecutive patients undergoing LNF were prospectively randomized into two similar groups that underwent division of the SGV, respectively, using bipolar cutting forceps (BPCF) or harmonic coagulating shears (HCS). Operative time, bleeding episodes, complications, equipment problems, and surgeon's subjective scoring of satisfaction and ease of use were assessed. RESULTS: Mean (+/-SD) time for fundic mobilization and division of the SGV was not significantly different between the two groups (BPCF = 20 +/- 12 min vs. HCS = 22 +/- 12 min). Bleeding events, estimated blood loss, surgeon satisfaction, and subjective ease of use were similar, and no transfusions were required. Complications in the BPCF group included a delayed gastric perforation requiring reoperation and two gastric serosal burns repaired intraoperatively. There was one splenic capsular tear using the HCS and one splenic capsular tear using the BPCF, both of which were controlled intraoperatively. The number of functional equipment problems were few and statistically similar. In the authors' institution, the per case total costs with capital expenditures amortized over 100 cases indicate savings of approximately $202/case with use of the BPCF versus the HCS. Regression analysis demonstrated a significant correlation between body mass index (BMI) and total case length and time for division of the SGVs. CONCLUSIONS: The BPCF and HCS appear to be equally efficacious for SGV division during LNF. Judicious application of both energy forms and heightened vigilance for gastric serosal injury are required with use of both the BPCF and HCS in cases of tight gastrosplenic adhesions or short SGVs. The BPCF carries a potential cost advantage over the HCS in the authors' institution. The BMI directly correlates with time required to divide SGVs and total length of LNF.