Twenty years of experience with laparoscopic antireflux surgery.

BACKGROUND: There are few reports of large patient cohorts with long-term follow-up after laparoscopic antireflux surgery. This study was undertaken to evaluate changes in surgical practice and outcomes for laparoscopic antireflux surgery over a 20-year period. METHODS: A standardized questionnaire, prospectively applied annually, was used to determine outcome for all patients undergoing laparoscopic fundoplication in two centres since commencing this procedure in 1991. Visual analogue scales ranging from 0 to 10 were used to assess symptoms of heartburn, dysphagia and satisfaction with overall outcome. Data were analysed to determine outcome across 20 years. RESULTS: From 1991 to 2010, 2261 consecutive patients underwent laparoscopic fundoplication at the authors' institutions. Follow-up ranged from 1 to 19 (mean 7.6) years. Conversion to open surgery occurred in 73 operations (3.2 per cent). Revisional surgery was performed in 216 patients (9.6 per cent), within 12 months of the original operation in 116. There was a shift from Nissen to partial fundoplication across 20 years, and a recent decline in operations for reflux, offset by an increase in surgery for large hiatus hernia. Dysphagia and satisfaction scores were stable, and heartburn scores rose slightly across 15 years of follow-up. Heartburn scores were slightly higher and reoperation for reflux was more common after anterior partial fundoplication (P = 0.005), whereas dysphagia scores were lower and reoperation for dysphagia was less common (P < 0.001). At 10 years, satisfaction with outcome was similar for all fundoplication types. CONCLUSION: Laparoscopic Nissen and partial fundoplications proved to be durable and achieved good long-term outcomes. At earlier follow-up, dysphagia was less common but reflux more common after anterior partial fundoplication, although differences had largely disappeared by 10 years.

Thoracoscopic and laparoscopic esophagectomy: initial experience and outcomes.

BACKGROUND: Although surgical resection currently is the preferred treatment for fit patients with resectable esophageal cancers, it is associated with a relatively high risk of morbidity and significant perioperative mortality. Currently, a range of open surgical approaches are used. More recently, minimally invasive approaches have become feasible, with the potential to reduce perioperative morbidity. This study investigated the outcomes from one such approach. METHODS: Outcome data were collected prospectively for 36 consecutive patients who underwent a minimally invasive esophagectomy for esophageal cancer. A three-stage approach was used, with all the patients undergoing a thoracoscopic esophageal mobilization, combined with either open or hand-assisted laparoscopic abdominal gastric mobilization, and open cervical anastomosis. An open abdominal approach was used for 15 of the patients and a hand-assisted laparoscopic approach for 21. A total of 34 patients had invasive malignancy, whereas 2 had preinvasive disease. A group of 23 patients (68%) who had invasive malignancies also received neoadjuvant chemotherapy and radiotherapy. RESULTS: The mean operating time ranged from 190 to 360 min (mean, 263 min). The median postoperative hospital stay was 16 days. In-hospital mortality was 5.5% (2/36), and perioperative morbidity was 41%. The perioperative outcomes for patients undergoing an open abdominal approach and those who had hand-assisted laparoscopic surgery were similar. For the patients who underwent a hand-assisted laparoscopic abdominal procedure, the total operating time was shorter (248 vs 281 min), and the blood loss was less (223 vs 440 ml). The median follow-up period was 30 months. The 4-year survival predicted by Kaplan-Meir for the 34 patients with invasive malignancy was 44%. CONCLUSION: The outcome for esophagectomy using thoracoscopic esophageal mobilization, with or without hand-assisted laparoscopic abdominal surgery, was comparable with data from conventional open surgical approaches. These approaches can be performed with an acceptable level of perioperative morbidity. Further application of these techniques, with close scrutiny of outcome data, is appropriate.

Endoscopic ultrasound for preoperative staging of esophageal carcinoma.

BACKGROUND: Endoscopic ultrasound (EUS) is potentially the best method for pretreatment staging of esophageal carcinoma once distant metastases have been excluded by other methods. However, its apparent accuracy might be influenced by the use of neoadjuvant therapy. To determine the accuracy of EUS in patients undergoing esophageal resection, the authors reviewed their experience with EUS. METHODS: A total of 73 patients with esophageal carcinoma who underwent an esophagectomy between April 2000 and February 2005 were examined using preoperative EUS and computed tomography (CT). Of these patients, 39 also underwent preoperative neoadjuvant chemoradiotherapy. Both EUS and CT scan were used to determine the depth of tumor penetration (T-stage) and the presence of lymph node metastases (N-stage). These results then were compared with staging determined after pathologic examination of the resected surgical specimen. RESULTS: For patients not undergoing neoadjuvant therapy, T-stage was accurately determined by EUS in 79%, N-stage in 74%, and tumor node metastasis (TNM) classification in 65% of the cases. However, when patients who had undergone neoadjuvant chemoradiotherapy were included, the overall accuracy of EUS was 64% for T-stage, 63% for N-stage, and 53% for TNM classification. For the patients who underwent neoadjuvant therapy, EUS indicated a more advanced T-stage in 49%, N-stage in 38%, and TNM classification in 51% of the cases, as compared with pathology. The overall accuracy of EUS for T- and N-stage carcinomas was superior to that of CT scanning. CONCLUSION: For patients who do not undergo preoperative neoadjuvant chemotherapy and radiotherapy, EUS is a more accurate method for determining T- and N-stage resected esophageal carcinomas. Neoadjuvant therapy, however, results in apparent overstaging, predominantly because of tumor downstaging, and this reduces the apparent accuracy of EUS (and CT scanning) in this patient group. Nevertheless, EUS staging before neoadjuvant therapy could be more accurate than pathologic staging after treatment, thereby providing better initial staging information, which can be used to facilitate treatment.

A randomized controlled trial to determine the effect of humidified carbon dioxide (CO2) insufflation on postoperative pain following thoracoscopic procedures.

BACKGROUND: It has previously been shown that the insufflation of humidified gas during laparoscopy results in less postoperative pain than is observed following the use of dry gas. Experimental evidence also suggests that dry gas insufflation during thoracoscopy results in greater structural injury to the pleura than occurs with the use of humidified gas. The present study was designed to determine the effect of humidified gas insufflation on postoperative pain following thoracoscopic procedures. METHODS: Forty consecutive patients were prospectively randomized. Twenty patients were insufflated with humidified carbon dioxide (CO(2)), and 20 control patients received standard dry CO(2). RESULTS: The patients' analogue pain score was significantly lower following humidified gas insufflation compared to dry gas insufflation when assessed at 6 h postoperatively, as well as on the 1st, 2nd, 3rd, and 14th postoperative days. The postoperative morphine consumption was lower in the humidified group than it was in the control group. The incidence of respiratory complications was identical for both groups. CONCLUSION: The use of humidified gas appears to reduce postoperative pain but not the rate of respiratory complications.

Endoscopic microsurgical dissection of the esophagus (EMDE).

This paper presents endoscopic microsurgical dissection of the esophagus (EMDE), a surgical technique for the therapy of esophageal cancer which improves blunt esophageal dissection with the aim of reducing postoperative morbidity and mortality. A mediastinoscope with integrated operative instrument channel, fibre bundles, optic and rinsing channel has been developed whereby precise and atraumatic esophageal dissection is possible via a cervical access incision. Between 1989 and 1993, 37 patients were operated on using the EMDE technique and are compared with 48 patients operated on during the same period by the thoraco-abdominal route. The operative duration was reduced by the new technique, and although the number of severe complications was not significantly different between both groups, the rate of pulmonary and cardiac complications was reduced. The mortality rate was 10% for EMDE patients and 14% for the thoraco-abdominal procedure, and there was no difference in the long-term survival rate. As distinct from procedures requiring a thoracotomy for esophageal dissection, EMDE permits ventilation of both lungs throughout the entire operation and reduces the total operative trauma.

Laparoscopic fundoplication in patients with an aperistaltic esophagus and gastroesophageal reflux.

A minority of patients with severe gastroesophageal reflux who present to surgeons for antireflux surgery have absent esophageal peristalsis when investigated before surgery with esophageal manometry. Some of these patients also have systemic sclerodema. While conventional wisdom suggests that these patients are at risk of a poor outcome if they proceed to fundoplication, some will have severe reflux symptoms, which are poorly controlled by medical therapy, and surgery will therefore offer the only chance of 'cure'. We performed this study to determine the outcome of laparoscopic fundoplication in the subset of patients with gastroesophageal reflux and an aperistaltic esophagus. From 1991 to 2003, the operative and follow-up details for all 1443 patients who underwent a laparoscopic fundoplication in our Departments have been prospectively collected on a database. These patients were then followed yearly using a standardized symptom assessment questionnaire. A subset of patients whose preoperative esophageal manometry demonstrated complete absence of esophageal body peristalsis and absent lower esophageal sphincter tone (aperistaltic esophagus) were identified from this database, and their outcome following laparoscopic fundoplication was determined. Twenty-six patients with an aperistaltic esophagus who underwent a laparoscopic fundoplication were identified. Six of these had a systemic connective tissue disease (scleroderma), and 20 had an aperistaltic esophagus without a systemic disorder. A Nissen fundoplication was performed in four patients, and an anterior partial fundoplication in 22. Follow-up extended up to 12 years (median, 6). A good overall symptomatic outcome was achieved in 88% at 1 year, 83% at 2 years and 93% at 5-12 years follow-up. Reflux symptoms were well controlled by surgery alone in 79% at 1 year, and 79% at 5-12 years. At 2 years, 87% were eating a normal diet. Two patients underwent further surgery - one at 1 week postoperatively for a tight esophageal hiatus, and one at 1 year for recurrent reflux. Patients with troublesome reflux and an aperistaltic esophagus can be effectively treated by laparoscopic fundoplication. An acceptable outcome will be achieved in the majority of patients.

Neoadjuvant chemoradiotherapy for esophageal carcinoma.

SUMMARY. Neoadjuvant chemoradiotherapy is often administered to patients with esophageal carcinoma in the belief that this will improve survival. However, its role in the management of esophageal carcinoma remains controversial. In this study we evaluated our experience with neoadjuvant chemoradiotherapy for the treatment of esophageal carcinoma. The study group was 115 patients who underwent esophagectomies between January 1999 and January 2004. Eighty-nine patients had adenocarcinoma and 26 had squamous cell carcinoma. Fifty-six patients underwent neoadjuvant chemoradiotherapy (two cycles of cisplatin and 5-fluorouracil with 45 Gy radiation) followed by esophagectomy. The other 59 patients proceeded directly to esophagectomy. Outcomes were determined prospectively, and follow-up was available for all patients. Neoadjuvant chemoradiotherapy achieved down-staging of the esophageal cancer in 43%, 43% and 46% of patients, according to T, N and TNM classifications, respectively. Neoadjuvant chemoradiotherapy resulted in a complete pathological response in seven (13%) patients. The surgical morbidity rate was 37% (42/115), and in-hospital mortality was 5% (6/115). There were no differences between patients who did and did not undergo neoadjuvant chemoradiotherapy in regard to completeness of resection, perioperative mortality and postoperative morbidity. Four-year survival was 33% following neoadjuvant chemoradiotherapy, compared with 19% for patients undergoing surgery alone. The administration of neoadjuvant chemoradiotherapy in patients with esophageal carcinoma down-staged nearly 50% of tumors, and a complete pathological response occurred in some of these patients. It was not associated with any increase in postoperative morbidity or perioperative mortality. In this non-randomized study, it was also associated with a trend towards a better survival outcome.

A randomised trial of ultrasonic dissection versus electrocoagulation to reduce lymphatic complications after surgery for recurrent sapheno-femoral incompetence.

OBJECTIVE: Prospectively to compare lymphatic drainage after ultrasonic dissection, an electrocoagulation technique and sharp dissection in the groin during surgery for recurrent sapheno-femoral incompetence. DESIGN: Prospective, randomised study comparing three surgical techniques. METHODS: Thirty-six consecutive patients undergoing surgery for recurrent sapheno-femoral incompetence were randomised. Twelve patients underwent dissection with ultrasound, 12 with electrocoagulation and 12 controls had sharp dissection with ligation of scar and lymphatic tissue using absorbable suture material. RESULTS: The mean drain output per patient was 13.5 ml in the ultrasonic group, 15.4 ml in the electrocoagulation group and 8.3 ml in the suture ligation group. Six minor cases of lymphatic leakage occurred in the ultrasonic group. This resulted in no clinical problem. There were no other significant differences between the three groups. CONCLUSIONS: There is no detectable advantage for the use of ultrasound or electrocoagulation in recurrent saphenous high ligation compared to sharp dissection.

The emerging role for laparoscopic gastrostomy.

A gastrostomy was fashioned laparoscopically in a 15 year old patient with a severe head injury. A preceding attempt at percutaneous endoscopic gastrostomy had failed. The gastrostomy tube was inserted into the stomach under vision and the stomach attached to the anterior abdominal wall by sutures.

Looking back to the advent of modern endoscopy: 150th birthday of Maximilian Nitze.

This year, 1998, marks the 150th anniversary of the birthday of Maximilian Nitze (1848-1906), a German scientist responsible for the initiation of modern endoscopy: He integrated two of his ideas in the construction of the first functional cystoscope. Nitze realized that the field of view during endoscopy could be enlarged by the use of an optical system, and that the light source should be placed on the tip of the instrument. He presented this cystoscope on October 2, 1877 for the first time, at age 28 years.

Durability and function of disposable versus reusable laparoscopic instrumentation.

The durability and function of reusable and disposable laparoscopic instruments are compared, and the relative advantages and disadvantages of each are illustrated. Familiarity with the relevant issues described should allow surgeons to make informed choices on the most suitable instruments for their specific situation.

A simplified technique for laparoscopic instrument ties.

A technique is described which simplifies intracorporeal knot-tying during laparoscopic surgery. The technique is applicable to both novice and experienced laparoscopic surgeons, and has ergonomic, cost and safety advantages over previously reported methods.

Intestinal ischaemia associated with carcinoid tumour: a case report with review of the pathogenesis.

A case of ischaemic ileal perforation associated with a macroscopically unapparent ileal carcinoid is described. The mesenteric vessels were non-pulsatile at operation but were anatomically patent when examined by the pathologist. The characteristic elastic perivascular sclerosis of mesenteric vessels, which probably caused a functional vascular obstruction, was only discovered after the histological sections were reviewed. The true incidence of this rare condition may be higher than previously suspected because the perivascular sclerosis can easily be overlooked. Awareness of the association between carcinoid tumour and mesenteric ischaemia may lead to early surgery and an improved outcome.

Study of venous blood flow changes during laparoscopic surgery using a thermodilution technique.

BACKGROUND: Many modalities exist to analyse those factors that contribute to venous stasis and deep venous thrombosis (DVT) during laparoscopic surgery. To the authors' knowledge intraoperative measurement of femoral venous blood flow has not yet been performed nor has the influence of sequential compression devices been assessed using this parameter. METHODS: The thermodilution technique similar to that employed in cardiac output measurement was used to determine changes in blood flow in the right femoral vein during laparoscopic cholecystectomy. Deep venous thrombosis prophylaxis involved perioperative use of sequential compression devices and subcutaneous heparin 5000 U. RESULTS: Pneumoperitoneum and the Trendelenburg position reduced femoral venous return in four of the six patients studied, but sequential compression devices failed to return blood flow to baseline in a predictable fashion. CONCLUSIONS: Although the measurement of blood flow using thermodilution is regarded as a reliable technique, during general anaesthesia the results may be susceptible to haemodynamic variations related to the anaesthetic agents as well as to the laparoscopic procedure. In addition sequential compression devices (when used alone) may not provide adequate prophylaxis against DVT because they do not predictably increase femoral blood flow.

Parathyroidectomy in the treatment of patients with chronic renal failure: a 10-year review.

The technique and outcome of surgery for the manifestations of secondary hyperparathyroidism are described. Forty-seven patients were analysed retrospectively over a 10-year period. Total parathyroidectomy and autotransplantation to the forearm was performed in all but five patients. Improvement occurred in 87 per cent of patients and there were no graft failures. Of six deaths, none was related to surgery. Four patients had recurrent hyperparathyroidism, three being graft dependent and one requiring re-exploration of the neck. Total parathyroidectomy and autotransplantation is a safe and effective approach. The major management problem was graft hyperplasia, seen in three of the 47 patients and managed by simple excision.

A comparison of laparoscopic and open hernia repair as a day surgical procedure.

To evaluate the merits of laparoscopic inguinal hernia repair (LHR) compared to conventional open hernia repair (OHR) a randomized study has been conducted. All patients were day surgical cases, of which 44 were randomized to a standardized OHR under local anesthetic (LA) and 42 to an LHR under general anesthesia (GA). Fifteen LHR patients had bilateral repairs. Operative time for OHR was 30.5 min, for unilateral LHR 35 min, and for bilateral LHR 60 min. OHR patients were discharged after a median of 134.5 min, which was significantly shorter than LHR patients, whose median discharge was 225 min (P < 0.01). Pain scores, activity levels, analgesia requirements, and time taken to return to work were not significantly different following surgery in either group (P < 0.05). There have been two recurrent hernias and one small bowel obstruction in the LHR group. We conclude that both repairs can be successfully performed as day surgical procedures. The added cost of LHR at this stage does not warrant its widespread use in unilateral hernia repairs. Which procedure is adopted should be individualized; however, patients with bilateral hernias on presentation can be successfully managed as day cases, obviating the need for hospitalization or two operations.

Hypothermia induced by laparoscopic insufflation. A randomized study in a pig model.

Hypothermia is a common postsurgical problem, yet information documenting the impact of laparoscopy on perioperative heat balance is scarce. This paper quantifies the changes in core temperature over a 3-h period of high-flow CO2 insufflation in a randomized, controlled trial of six pigs. Each animal was anesthetized and studied on three occasions under standardized conditions, acting as its own control via insufflation with no gas compared with insufflation by cold gas and warmed gas. Insufflation of CO2 gas at high-flow rates over a prolonged period of time results in a significant fall in core temperature. The provision of warmed rather than cold insufflated gas confers no protection against changes in core temperature during laparoscopic surgery due to the small amount of heat required to warm the gas to body temperature. A much greater effect is the latent heat required to saturate the insufflated gas. Most of the hypothermic effect is due to this, and could be minimized by humidifying the flow.

Physiological outcome following laparoscopic highly selective vagotomy. A controlled study in a pig model.

Open highly selective vagotomy (HSV) has withstood the rigors of objective evaluation to become the optimal surgical treatment for chronic duodenal ulcer refractory to medical therapy in many centers. Laparoscopic HSV has not been subjected to the same scrutiny before entering clinical practice. A controlled animal study was conducted to demonstrate the physiological validity of laparoscopic HSV. Experimental groups underwent laparoscopic and open highly selective vagotomies, and control groups underwent a sham laparoscopic gastric mobilization or no operative procedure. Gastric acid output was measured by an aspiration technique, liquid gastric emptying was calculated by the double sampling technique of George, and gastroesophageal reflux was assessed by 8-h ambulatory pH monitoring. Laparoscopic HSV was as effective as its open counterpart in reducing basal acid output, and laparoscopic HSV did not interfere with liquid gastric emptying in contrast to open HSV. Neither open nor laparoscopic HSV was observed to precipitate gastroesophageal reflux. These data suggested that the continued use of laparoscopic HSV in clinical practice is appropriate.

Combined thoracoscopic and laparoscopic oesophagectomy and oesophagogastric reconstruction.

Subtotal oesophagectomy and stapled oesophagogastric anastomosis is a favoured option for cure or palliation of oesophageal carcinoma. This approach currently involves a thoracotomy and laparotomy exposing the patient to the attendant pulmonary and intrathoracic complications. Alternative approaches to oesophagectomy without thoracotomy have failed to diminish the complication rate and may compromise the chance of cure. An endoscopic approach to the oesophagus is considered to be an evolving solution because it removes the need for thoracotomy and laparotomy but adheres to established oncologic principles. In order to assess the feasibility of complete endosurgical oesophagectomy and immediate reconstruction a non-survival study using 10 pigs was undertaken. Under general anaesthesia a 3-step operation was performed consisting of thoracoscopic oesophageal dissection, laparoscopic gastric mobilisation and thoracoscopic oesophagogastric anastomosis using a circular endoluminal stapler (Stealth-Ethicon). Conversion to open surgery was required only once during a gastric dissection, and all anastomoses were safely constructed thoracoscopically. In three animals small anastomotic tears were repaired with endoscopically-placed sutures. Three animals died intraoperatively, two from an anaesthetic complication prior to the introduction of intra-operative monitoring, and the other following haemorrhage from an hepatic vein traumatised by a liver retractor. This study has shown that endosurgical oesophagectomy is technically feasible and stapled oesophagogastric anastomosis can be performed in a comparable manner to the conventional procedure.

Bronchial anatomy and single-lung ventilation in the pig.

PURPOSE: To explore why two pigs died in the course of a study in which a double-lumen tube (DLT) was used to achieve single-lung ventilation, the bronchial anatomy of all six pigs involved in the study was examined at autopsy. METHODS: Autopsy involved examination of the lungs in situ and subsequent dissection of the lung tissue from the lobular bronchi. RESULTS: All six pigs were found to have an apical lobe (or lobular) bronchus arising from the trachea. In three it was on the right, as is usual in pigs, and in three, including the two that died, it was on the left. The mainstem bronchi to both lungs were short in all pigs, with major segmental bronchi arising just distal to the carina. CONCLUSION: The bronchial anatomy of the pig is such that the inflated cuffs of commercially available DLTs may cause partial or complete obstruction of the apical bronchi of one or both lungs, regardless of the side of the tracheal bronchus. The transmission of the resulting breath sounds across the narrow pig thorax can make auscultation unhelpful in assisting with optimal tube placement.