Video-assisted surgical management of achalasia of the esophagus.

PURPOSE: Video-assisted surgical approaches to esophageal achalasia continue to be explored by many surgeons involved in the management of this motor disorder. We report our experience with thoracoscopic and laparoscopic esophagomyotomy to more clearly define the efficacy and safety of these approaches. PATIENTS: Over 73 months, 58 patients with achalasia underwent thoracoscopic myotomy (n = 19) alone or laparoscopic myotomy (n = 39) with partial fundoplication (anterior = 15; posterior = 24). Mean age was 47.2 years and average length of symptoms was 60 months. Primary symptoms were as follows: dysphagia, 100%; pulmonary abnormalities, 22%; weight loss; 47%, and pain, 45%. Mean esophageal diameter was 6 cm and tortuosity was present in 16% (9/58) of patients. Prior management consisted of dilation (n = 47), botulinum toxin injection (n = 8), and prior myotomy (n = 1). METHODS: In the operating room all patients underwent endoscopic examination and evacuation of retained esophageal contents. The esophagomyotomy was extended 4 cm superiorly and inferiorly to 1 cm beyond the lower esophageal sphincter. Thoracoscopic and laparoscopic procedures were completed in all patients without conversion to an open operation. Mean operative time was 183 minutes (+/-58.1) and hospital stay averaged 2.3 days (+/-0.8). There was no operative mortality. The 1 operative complication was a perforation that was identified during the operation and repaired thoracoscopically. RESULTS: Symptoms improved in 97% of patients. Mean dysphagia scores (range 0-10) decreased from 9.8 +/- 1.6 before the operation to 2.0 +/- 1.5 after the operation (P <.001) at a mean follow-up of 6 months. Postoperative reflux symptoms developed in 5% (1/19) of the thoracoscopy group and 8% (4/39) of the laparoscopy group. Nine patients have persistent or recurrent dysphagia (16%). Seven patients have successfully undergone Savary dilation, and 2 required esophagectomy to manage recalcitrant dysphagia. CONCLUSION: At this intermediate term analysis, video-assisted approaches for management of achalasia are a reasonable alternative to extended medical therapy or open operations.

Laparoscopic approach to L4-L5 for interbody fusion using BAK cages: experience in the first 58 cases.

STUDY DESIGN: Operative reports were reviewed for patients who underwent laparoscopic fusion at the L4-L5 level and information regarding the mobilization of the vessels was recorded. OBJECTIVE: The purpose of this study was to describe variations in the approach used to address anatomical variations in the location of the great vessel bifurcation in the region of the L4-L5 intervertebral disc space when performing laparoscopic interbody fusion procedures. SUMMARY OF BACKGROUND DATA: Recent interest in laparoscopic spine surgery using threaded cages has resulted in questions regarding the ability to safely access the L4-L5 disc using this approach. The laparoscopic transperitoneal approach to L5-S1 is below the bifurcation of the great vessels, thus requiring minimal mobilization of the iliac vessels. However, the transperitoneal approach to L4-L5 may be complicated by the bifurcation of the great vessels anterior to this disc space. Difficulty in placing two cages may occur if the vessels cannot be adequately mobilized. METHODS: Data were collected for the consecutive series of the first 58 patients (40 males, 18 females; mean age 42.5 years) undergoing laparoscopic anterior lumbar interbody fusion (ALIF) at the L4-L5 level using BAK cages. Operative notes were reviewed to determine variations in the operative approach. In particular, it was recorded if the L4-L5 disc was accessed above, or below the bifurcation of the aorta and the vena cava, or between these structures. The blood loss, operative time, and length of hospitalization were compared with respect to approach variation. RESULTS: In 30 patients, the L4-L5 disc was accessed above the great vessel bifurcation, in 18 patients below the bifurcation, and in the remaining 10 patients, by passing between the vessels. There were no statistically significant differences in the operative time, blood loss, or length of hospitalization with respect to the approach used. Three patients were converted to open procedures as a result of bleeding from segmental veins. None required transfusions and there were no postoperative sequelae. In two patients, successful endoscopic repair of segmental vein avulsion from the vena cava was performed using endoscopic loop ligatures. One patient had a secondary procedure to remove a cage that was causingnerve irritation, and one patient reported retrograde ejaculation after a two level fusion. Another patient, in whom a posterior herniation was removed, later presented with a cerebrospinal fluid leak. Most of the operative complications occurred early in the series. CONCLUSIONS: Laparoscopic transperitoneal approach to L4-L5 for insertion of threaded fusion cages is feasible. The laparoscopic L4-L5 procedure can be accomplished with few complications, provided a dedicated team of collaborative surgeons with experience in laparoscopic spine techniques is employed. Variations in vascular anatomy did not prevent successful insertion of two threaded fusion cages.

Laparoscopic fusion of the lumbar spine in a multicenter series of the first 34 consecutive patients.

The purpose of this study was to describe the development of the laparoscopic technique for anterior lumbar fusion and to evaluate the clinical results of a first case series of patients. The in vivo porcine model was used first to develop the technique of transperitoneal laparoscopic interbody fusion. Afterwards, operative time, blood loss, perioperative complications and length of stay were recorded for the first 34 patients who underwent laparoscopic fusion of L4-5 or L5-S1 at two medical centers in 1994. Laparoscopic lumbar fusion was successful in 30 of 34 patients. Four patients early in the series successfully were converted to an open procedure because of poor visualization (two cases) or iliac venous injury (two cases). Transfusion was required in one patient; average blood loss was 128 ml. Operative time averaged 218 min, hospitalization 3.67 days. Laparoscopic fusion is feasible and has minimal complications when a skilled laparoscopic surgeon is present for exposure. Minimal excisional trauma associated with this technique should result in decreased hospitalization and earlier recovery compared with standard open techniques. Preliminary results indicate an earlier discharge and return to work (3 weeks) than that expected for standard open techniques.

Thoracoscopic transdiaphragmatic approach for adrenal biopsy.

The role of thoracoscopy for the management of intrathoracic diseases has expanded with advancement in endoscopic instrumentation and technology. We report a case of thoracoscopic transdiaphragmatic biopsy of an adrenal gland for metastatic carcinoma. The procedure was uncomplicated and the patient was discharged on the second postoperative day. The morbidity of traditional approaches for adrenal operation was avoided. Thoracoscopy may be a useful approach in selected patients for adrenal operation.

Present role of thoracoscopy in the diagnosis and treatment of diseases of the chest.

Since thoracoscopy was originally described in 1910, the application has been limited mainly to the diagnosis and treatment of pleural disease. Recent advancements in endoscopic equipment and refinement of surgical techniques have expanded the application of this procedure. Using video thoracoscopic techniques in 70 patients over the past 9 months, we have been able to perform a variety of procedures previously accomplished by "open" techniques. These procedures include (1) wedge resections of pulmonary nodules in 21 patients, using endoscopic mechanical stapling devices; (2) excision of the pericardium and drainage of the pericardial space in 6 patients; (3) dorsal thoracic sympathectomy in 6 patients; (4) apical blebectomy and pleurodesis in 6 patients; (5) lung biopsies for diagnosis of diffuse lung disease in 5 patients. Additional procedures performed include biopsy of hilar masses (3), biopsy of esophageal mass, excision of a mediastinal cyst, and the drainage of a spinal abscess. The remaining 20 procedures were performed for the diagnosis and treatment of pleural disease. There was no mortality associated with the procedure and morbidity was lessened, compared with standard thoracotomy procedures. The postoperative hospital stay after elective procedures performed in well patients averaged 3 days and was often as short as 1 day. Our experience indicates a markedly expanded role for thoracoscopy in the diagnosis and treatment of thoracic diseases with less postoperative morbidity.

Percutaneous localization of pulmonary nodules for thoracoscopic lung resection.

A limiting factor in removing pulmonary nodules by videothoracoscopic techniques is the inability to locate lesions deep within the substance of the lung. We describe a technique in which a hook wire commonly used to localize nonpalpable breast lesions is placed percutaneously into the lung nodule preoperatively. Using the wire anchored into the lung as a guide, the target lesion can be successfully identified and removed thoracoscopically.

Dilemmas in dealing with the blue toe syndrome: aortic versus peripheral source.

Six patients with unilateral blue toe syndrome presented a diagnostic dilemma with regard to the source of embolization: central aortic versus peripheral. Two patients had moderately severe aortoiliac atherosclerosis associated with focal stenoses in the superficial femoral arteries, and four patients had mild aortoiliac disease associated with localized plaques confined to either the superficial femoral or popliteal arteries. In all patients, it was elected to explore the peripheral lesions first. At operation, ulcerated plaques or focal stenoses were found, and all lesions had adherent white thrombi on their surfaces. All patients were treated either by localized thromboendarterectomy or short reversed saphenous vein grafting. There was no morbidity or mortality. Recurrent embolization did not occur during a follow-up of 8 to 24 months. Distal atherosclerotic lesions should be sought to explain distal embolization before more complex aortoiliac disease is incriminated. In the presence of concomitant aortoiliac disease, it is mandatory to directly explore the peripheral lesion, open the artery, and carefully examine the lesion in situ. Thrombus adherent to the surface of an ulcerated plaque is evidence of an embolizing source. This approach is associated with minimal morbidity and may be curative. If these findings are not present, it would be appropriate to proceed with staged correction of aortoiliac disease.