Feasibility and Efficacy of Magnetic Sphincter Augmentation for the Management of Gastroesophageal Reflux Disease Post-Sleeve Gastrectomy for Obesity.

BACKGROUND: Patients with medically intractable GERD after laparoscopic sleeve gastrectomy (LSG) have limited surgical options. Fundoplication is difficult post-LSG. Roux-en-Y gastric bypass may be used as a conversion procedure but is more invasive with potential for serious complications. Magnetic sphincter augmentation (MSA) is a less invasive GERD treatment alternative. The objective of this study was to assess safety and efficacy outcomes of MSA after LSG. METHODS: The primary outcome of this observational, multicenter, single-arm prospective study was the rate of serious device and/or procedure-related adverse events (AEs). The efficacy of the LINX device was measured comparing baseline to 12-month post-implant reductions in distal acid exposure, GERD-HRQL score, and average daily PPI usage. RESULTS: Thirty subjects who underwent MSA implantation were followed 12 months post-implant. No unanticipated adverse device effects were observed. There were two adverse events deemed serious (dysphagia, pain, 6.7%) which resolved without sequelae. GERD-HRQL scores showed significant improvement (80.8%, P < 0.001), and reduction in daily PPI usage was seen (95.8%, P < 0.001). Forty-four percent of subjects demonstrated normalization or > = 50% reduction of total distal acid exposure time (baseline 16.2%, 12 months 11%; P = 0.038). CONCLUSIONS: Post-LSG, MSA showed an overall improvement of GERD symptoms, and reduction in PPI use with explants within anticipated range along with improvement in distal esophageal acid exposure time.

Minimally invasive surgical practice: a survey of general surgeons in Ontario.

INTRODUCTION: With the rapidly evolving techniques for minimally invasive surgery (MIS), general surgeons are challenged to incorporate advanced procedures into their practices. We therefore carried out a study to assess the state of MIS practice in Ontario. METHODS: A questionnaire was mailed to 390 general surgeons in Ontario. It addressed the surgeon's practice demographics, performance of both basic and advanced MIS procedures, the factors influencing this practice and the means of obtaining MIS training. RESULTS: Of the 390 general surgeons surveyed, 309 (79%) responded. Thirty-six of these were retired and were excluded from the analysis, leaving 273 available for study. The average age in the study group was 49.7 years; 247 (90%) were men. Of 272 who responded to the question, 116 (43%) had subspecialty training. The average surgeon's operating room (OR) time was 1.5 d/wk and the average waiting time for elective procedures was 4 weeks. We found that 257 (94%) respondents performed basic laparoscopic procedures, and 164 (60%) performed appendectomy; 135 (49%) performed at least 1 advanced laparoscopic procedure in their practice, although only 30 (22%) of these performed inguinal hernia repair. Using a Likert scale, we found that the most important factors influencing the incorporation of advanced laparoscopic procedures into surgical practice were a lack of OR time (median 4), lack of OR financial resources (median 4) and lack of training opportunities (median 4). Of surgeons responding to questions, 161 (64%) of 251 felt that the present medical environment did not allow them to meet standard-of-care requirements; they felt that it was the responsibility of academic surgical departments (214 [80%] of 268), the Canadian Association of General Surgeons (177 [68%] of 262) and the Ontario Association of General Surgeons (141 [53%] of 264) to provide continuing medical education courses for MIS training. CONCLUSION: The ability of practising general surgeons to incorporate advanced MIS procedures into their surgical practice remains a complex issue.

Minimally invasive adrenalectomy for pheochromocytoma during pregnancy.

Pheochromocytoma during pregnancy is a very rare condition; fewer than 200 cases have been reported in the literature. We present the case of a 24-year-old pregnant woman found to have a pheochromocytoma during investigation of abdominal pain. This is the second reported case of laparoscopic adrenalectomy for pheochromocytoma detected during pregnancy. After appropriate radiologic investigation and medical management, a laparoscopic left adrenalectomy was performed at the beginning of the second trimester. There were no complications, and she was delivered of a healthy baby at term. We review the management of pheochromocytoma in pregnant patients and discuss the role of laparoscopy.

The ethics of applying new medical technologies.

Medical technology itself, including minimally invasive surgery, has no morals; our morality revolves around when and how we use technology. This often involves the individual clinician's assessment of their own abilities and an awareness of two aspects of the technology: its proven efficacy and its safety. Is technology outpacing knowledge? Or do physicians adopt new technologies in a responsible way with good motives? No one knows for sure. Technological progress in medicine has been a mixed blessing. The only ethical element involved in the use of new technologies over which individual medical practitioners have control, is that of user proficiency with the device, procedure, or drug, and the related information they provide to their patients when obtaining their consent for its use. New technologies fall into two broad categories: evolutionary, the most common, and revolutionary, which occur sporadically and may completely change the face of medical care. The learning curve for all new technologies can be steep. So, when should physicians be permitted to use these new technologies without supervision? Who is responsible for setting and monitoring standards for new technologies? With the moving target of medical technological innovation, individual practitioners are primarily responsible for the ethical use of new (to them) technologies. It is physicians' ethics that govern their use of new technologies, being certain that they have the requisite training and experience to use the modality, and that the intervention is safe for their patients. Institutional practitioner credentialing at the local level, despite its faults, will often be the primary control over a technology's use. What will ultimately govern the use of new technologies is the ethics (if they exist) of healthcare institutions and individual practitioners, as well as patient need. This is simply another reason why ethics education is vital for physicians-and other health practitioners and healthcare administrators.