Calibración cardial y vagotomía supraselectiva laparoscópica con cinco trocares en reflujo gastroesofágico patológico / Cardial calibration and laparoscopic supraselective vagotomy with 5 trocars in pathologic gastroesophagic reflux

Las técnicas de fundoplicatura, para el tratamiento del Reflujo Gastroesofágico Patológico, presentan resultados comparables con la cirugía efectuada por vía abierta. Variaciones de técnicas han sido reportadas en la literatura tanto en la posición, número de trocares, ubicación del equipo quirúrgico, como de la técnica antirreflujo propiamente tal. En este artículo se describe la técnica de calibración cardial y vagotomía supraselectiva efectuada en 15 pacientes por vía laparoscópica usando 5 trocares. El tiempo operatorio y complicaciones intraoperatorias son similares a estudios previos, sin conversión a cirugía abierta, reoperaciones, ni mortalidad operatoria. Los estudios manométricos comparando pre y postoperatorio demostraron significativa mejoría de la competencia esfinteriana y clínicamente no hay recidiva de los síntomas a corto plazo. Los resultados demuestran la factibilidad de esta técnica como alternativa de tratamiento del Reflujo Gastroesofágico por vía laparoscópica

Laparoscopic management of peptic ulcer disease.

Laparoscopic surgery has heralded a new era for the operative management of peptic ulcer disease. With a mean hospital stay of 3.5 days,22 a recurrence rate of 4% to 11%,1,3 and a morbidity from dumping and diarrhea of 1% to 2%,21 laparoscopic proximal gastric vagotomy can truly provide a good alternative to medical therapy. Despite the high cost of medical care and surgical equipment, a laparoscopic vagotomy should be cost effective compared with life-long pharmacologic management of peptic ulcer disease. Several different operative procedures have been discussed, with similar outcomes. The surgeon has a choice of several approaches, depending on his or her training and level of skill. As surgeons gain experience with laparoscopic surgery, we are able to offer consistently good results with low recurrence rates and negligible morbidity and mortality. Minimally invasive surgery has rekindled the operative treatment of peptic ulcer disease.

Laparoscopic technique of proximal selective vagotomy.

Proximal selective vagotomy (PSV) is an effective, definitive therapy for peptic ulcer disease of the duodenum. Long-term studies have shown that ulcer recurrence occurs in less than 10% of patients if the operation is performed by an experienced surgeon. Since PSV does not influence gastric emptying, side effects such as diarrhea, gastric stasis or the dumping syndrome are rare. Due to this favorable experience, PSV is our preferred technique for the laparoscopic approach to peptic ulcer disease. We have performed this operation in 13 patients. Indications were chronic duodenal ulceration unresponsive to medical therapy, chronic duodenal ulceration combined with reflux esophagitis, and reflux esophagitis due to gastric acid hypersecretion. In patients with reflux esophagitis PSV was performed in addition to an antireflux procedure. Laparoscopic PSV can be performed more accurately than the open procedure since it allows for better visualization with less possibility of missing small vagal connections to the parietal cells such as the 'criminal nerve'. The median duration of operation was 3 hours. There were no serious peri- or postoperative complications. The median time of postoperative hospital stay was 3 days. During the median follow-up of 27 months no recurrence of duodenal or esophageal ulceration was encountered and none of the patients complained of epigastric pain, diarrhea or dumping symptoms.

[Laparoscopic vagotomy in the treatment of duodenal ulcer with a report of 3 cases]. / Laparoskopska vagotomiia pri lechenieto na duodenalnata iazva s prinos na tri sluchaia.

The report deals with posterior truncus and anterior supraselective vagotomy, performed laparoscopically for the first time in this country. Three patients-2 women and one man-are operated on for duodenal ulcer,complicated with bleeding, controlled conservatively in the first stage. In one female patient the intervention described and cholecystectomy are simultaneously done. In none of the three patients is stenosis of the pylorus observed. A considerable reduction of operative time-to 95 and 83 minutes-is achieved when special instrumentation (Multifire Endo Gia) for automated linear resection of the anterior gastric wall is used. Emphasis is laid on a number of advantages of the technique described.

Vagotomía supraselectiva más piloroduodenoplastía: técnica quirúrgica / Supraselective vagotomy plus pyloroduodenoplasty: surgical technique

Se presenta la experiencia de 12 pacientes portadores de úlcera duodenal con deformidad y estenosis del bulbo duodenal evaluados con endoscopia y estudio radiológico baritado y con indicación quirúrgica por recurrencia de la enfermedad ulcerosa. Estos pacientes fueron sometidos a vagotomía supraselectiva asociada a piloroduodenoplastia. Se describe la técnica y los resultados del postoperatorio inmediato

Laparoscopic proximal gastric vagotomy.

Proximal gastric vagotomy, considered the conventional surgical treatment of choice for peptic ulcer disease, is now performed laparoscopically. Thirty-three patients underwent the procedure. Seven patients were treated on an emergency basis for perforated peptic ulcer. Morbidity and mortality of the procedure were zero. Patient acceptance (Visick staging) was good to excellent in 22 of 25 patients in follow-up. Laparoscopic proximal gastric vagotomy appears to be a good treatment in chronic peptic ulcer disease even when complicated by an acute perforation.

Laparoscopic posterior truncal vagotomy and anterior proximal gastric vagotomy.

Simplified parietal cell vagotomies (Taylor's and Hill-Barker's procedures) were proposed more than a decade ago to make the operation easier and faster. Efficacy and safety have proven to be as good as with proximal gastric vagotomy. The Hill-Barker operation is particularly simplified by the laparoscopic approach, which enables the procedure to be performed very precisely. The limited trauma of minimally invasive vagotomy has increased the interest in peptic ulcer surgery, especially for patients with chronic duodenal ulcer disease who cannot or do not want to take long-term continuous medication, or who are resistant to it. We describe our technique of performing the laparoscopic Hill-Barker procedure. Our initial results with eleven patients show no operative mortality and minimal morbidity with early discharge and ulcer of all patients. Of the 9 cases which are evaluable, 8 are pain-free and one had an ulcer recurrence after incomplete vagotomy.

Laparoscopic proximal gastric vagotomy--neuralgic points of technique.

Laparoscopic proximal gastric vagotomy is a valuable therapeutic tool in the management of patients suffering from recurrent duodenal ulcer disease, the therapeutic principle being the effective reduction of gastric acid output without gastrotomy or gastric resection. The method is based on the well-documented conventional technique, which has been evaluated for over 15 years. The division of all vagal fibres to the gastric fundus and body is essential for complete vagotomy in order to ensure a sufficient reduction in gastric acid. The operation time is between 2 and 3 hours. Eighteen patients have been treated successfully with this minimally invasive and safe procedure in our unit. The functional and cosmetic results are excellent. The comparatively lower costs are, last but not least, an important advantage.

Laparoscopic gastric vagotomies.

Recurrent duodenal ulcer remains a continuing challenge for medical care. Once popular, operations have almost vanished from surgical wards due to efficient medical treatment. The onset of laparoscopy and minimal invasive surgery has caused several teams to reconsider the position of surgical treatment in the disease. Various procedures are actually used, and, as no long-term follow-up is available, it is difficult to estimate which technique would be advisable. The authors compare the different procedures and the theoretical advantages and disadvantages of each one. The best technique has to be applicable in laparoscopy and achieve the best results for the patient.

Highly selective vagotomy: use of a ligature carrier.

A ligature carrier for use in typing the neurovascular bundle along the lesser curve of the stomach during highly selective vagotomy is described. This is presented as a safe and efficient way of performing this part of the operation.

[Laser vagotomy in the treatment of duodenal ulcer]. / Lazernaia vagotomiia v lechenii iazvennoi bolezni dvenadtsati- perstnoi kishki.

In 79 patients with duodenal ulcer disease, the selective proximal vagotomy (SPV) with the use of the "Scalpel-1" CO2-laser was performed. In the experiment, it is shown that after dissection of the nerve trunks by the laser scalpel, no regeneration of neural tissue is observed. After laser SPV, the suppression of gastric acid production is more stable than after conventional vagotomy, the number of ulcer recurrences is lower.

Lesser curve disconnection using a stapling device: highly selective vagotomy made quicker and easier.

A stapling device has been used to disconnect the lesser curve of the stomach during highly selective vagotomy in a consecutive series of ten patients. This modification renders the operation technically easier and quicker to perform. Postoperative recovery was uneventful in all patients, and in the subsequent follow-up period of 7-15 months, no problems relating to the technique were encountered.

[Stapling devices on stomach and small bowel (author's transl)]. / Klammernahtgeräte an Magen und Dünndarm.

Sutures, blind closures, and anstomoses can be performed on the stomach and the small bowel with LDS, GIA, TA, and EEA staplers. The advantage of using these devices is a fast, clean operation, with safety comparable to the conventional technique. Leakage in sutures and anastomoses occur in 1% and after duodenal closure in 2.6%. Bleeding has been observed with the GIA and LDS staplers (0.7%-1%). Mortality is equal to the conventional technique. The time saved during operations and fewer infections justify the elevated costs of the stapling devices.