Adam Spivack

Incisionless revision of post-Roux-en-Y bypass stomal and pouch dilation: multicenter registry results.

BACKGROUND Surgical revision for weight regain after Roux-en-Y gastric bypass (RYGB) has been tempered by the high complication rates associated with standard approaches. Endoluminal revision of stoma and pouch dilation should intuitively confer a better risk profile. However, questions of clinical safety, durability, and weight loss need to be answered. We report our multicenter intraoperative experience and postoperative follow-up to date using the Incisionless Operating Platform for this patient subset. METHODS The patients who had regained significant weight >or=2 years after RYGB after losing >or=50% of excess body weight after RYGB were endoscopically screened for stomal and/or pouch dilation. Qualified patients underwent incisionless revision using the Incisionless Operating Platform to reduce the stoma and pouch size by placing anchors to create tissue plications. Data on the safety, intraoperative performance, postoperative weight loss, and anchor durability were recorded to date as a part of 2 years of postoperative follow-up. RESULTS A total of 116 consecutive patients were prospectively studied. Anchors were successfully placed in 112 (97%) of 116 patients, with an average intraoperative stoma diameter and pouch length reduction of 50% and 44%, respectively. The operating room time averaged 87 minutes. No significant complications occurred. At 6 months after the procedure (n = 96), an average of 32% of weight regain that had occurred after RYGB had been lost. The percentage of excess weight loss averaged 18%. The 12-month esophagogastroduodenoscopy results confirmed the presence of the anchors and durable tissue folds. CONCLUSIONS Incisionless revision of stoma and pouch dilation using the Incisionless Operating Platform can be performed safely. The data to date have demonstrated mild-to-moderate weight loss, and the early 12-month endoscopic images have confirmed anchor durability. Patients were actively followed up to document the long-term durability of this intervention in the entire patient subset.

Transrectal Endoscopic Retrorectal Access (TERA): A Novel NOTES Approach to the Peritoneal Cavity

BACKGROUND As the field of natural orifice translumenal endoscopic surgery (NOTES) expands, new access sites are being investigated. One access site to the peritoneal cavity, which has not been the subject of much investigation, is transrectal access. The aim of this article is to describe a new method to peritoneal access: transrectal endoscopic retrorectal access (TERA). MATERIALS AND METHODS Three pigs were placed in the supine position under general anesthesia, and an umbilical port was placed for the pneumoperitoneum, as well as visualization of the pelvic dissection and access. A rectotomy was made under direct vision above the dentate line posteriorly. The flexible endoscope was introduced into the retrorectal space, balloon dilation was used to open and dissect the retrorectal plane, and the peritoneal cavity was entered with a needle knife. After peritoneal exploration, the endoscope was withdrawn and the rectotomy was closed under direct vision. RESULTS Each of the 3 cases was successful with entry into the peritoneal cavity to the right of the sacral promontory. Direct visualization allowed the avoidance of injury to the ureter, vessels, and nervous structures of the pelvis. The flexible endoscope allowed an easy direct visualization of the upper abdominal organs. In addition, retroflexion allowed a view of the pelvic organs. Mean operative time was 40 minutes. CONCLUSIONS TERA is a novel access route to the peritoneal cavity that can be performed by using readily available instrumentation. When performed under direct view, injury to the adjacent structures can be avoided while obtaining access. Unresolved issues include sterility of the procedure and reproducibility, and future survival studies will delineate long-term safety.

Robotic single-incision transabdominal and transvaginal surgery: initial experience with intersecting robotic arms

Single‐incision laparoscopic and natural orifice translumenal endoscopic surgery (NOTES) are technically challenging methods. Robotics might have the potential to overcome such hurdles with computer technology.

Early Ambulation after Percutaneous Femoral Access with Use of Closure Devices and Hemostatic Agents

BACKGROUND Patient satisfaction after percutaneous endovascular procedures is significantly influenced by the amount of time to ambulation postprocedure. The purpose of this study was to assess the complication rates of early ambulation after use of closure devices or topical hemostatic agents for femoral access sites for endovascular procedures. METHODS A retrospective review was performed of all patients who underwent an endovascular procedure from a femoral access site between January 2004 and March 2008. The access site was closed with an Angio-Seal, StarClose, or D-Stat Dry with pressure. Patients ambulated 2 hr postprocedure when a closure device was used and 4 hr postprocedure when a D-Stat pad was applied. Access-site bleeding complications were assessed. Sheath size, closure method, patient characteristics, and antiplatelet status were analyzed. RESULTS A total of 245 patients with a mean age of 70 years were identified. Of these, 154 (63%) patients were treated with a D-Stat pad with pressure, Angio-Seal was used on 83 (34%), and StarClose was used on eight (3%). The overall complication rate was 5.7%. Complications increased with increasing age (p = 0.003) and use of StarClose (p = 0.0001). The D-Stat pad was associated with a decreased complication rate (p = 0.03). Sheath size did not influence the incidence of bleeding. There was no significant increase in complications in patients taking an antiplatelet agent. CONCLUSION With a protocol using closure devices and hemostatic agents, early ambulation after percutaneous femoral access can be achieved safely with an acceptable complication rate in patients with peripheral vascular disease.

639 NOTES Transvaginal Appendectomy

Background: Patients operated on for gallstone disease often receive prophylactic antibiotics especially in acute operations but frequently also in elective surgery even though evidence for the effectiveness of such treatment is lacking. In this study we present data on the use of prophylactic antibiotics and postoperative infections from a national, web based register of gallstone surgery. Methods: The Swedish Register for Gallstone Surgery and ERCP (GallRiks) started in May 2005 and soon reached a national coverage with 75% of all procedures being entered in 2007. It comprises open and laparoscopic surgery of the gallbladder as well as all endoscopic interventions of the bile ducts. GallRiks is an internet application with on line registration of procedures and follow up as well as electronic reports on demand. A program for validation of data has started and the results from the first 6 hospitals revised indicate a match between the medical records and the database in 98.6% of the cases. During 2006 and 2007 a total of 16400 operations were registered in GallRiks. Patients from hospitals who had registered less than 25 patients were excluded from this study as were patients who had either a major surgery along with the cholecystectomy or only had a choledochotomy (previous cholecystectomy). Incomplete records and cases with a missing 30-day follow up were also excluded. Altogether 747 patients (4.6%) were excluded for these reasons. In another 4726 patients (30%) the surgery was performed acute. Thus, this is a study of 10927 patients who had an elective cholecystectomy performed in 54 Swedish hospitals during the years 2006 and 2007. Results: The 54 hospitals used prophylactic antibiotics at very different rates, from 0% to 98% of the operations, which by far exceeds any random variation. A postoperative abscess was found in 93 (.9%) and in 377 patients (3.5%) some kind of septic complication occurred requiring antibiotic treatment. In a multiple logistic regression analysis, adjusting for age, sex, indications for surgery, surgical methods and operative difficulties peroperative antibiotics had no beneficial effect on the risk of postoperative septic complications. Conclusion: There is a huge variation in the use of prophylactic antibiotics in elective cholecystectomy between different hospitals in Sweden reflecting the lack of uniform guidelines. The rate of septic complications from this operation is low and is furthermore unaffected by prophylactic antibiotics.

641 Transrectal Simulated Appendectomy in a Porcine Model with Novel Balloon Dilation in Retroperitoneum

Background: Patients operated on for gallstone disease often receive prophylactic antibiotics especially in acute operations but frequently also in elective surgery even though evidence for the effectiveness of such treatment is lacking. In this study we present data on the use of prophylactic antibiotics and postoperative infections from a national, web based register of gallstone surgery. Methods: The Swedish Register for Gallstone Surgery and ERCP (GallRiks) started in May 2005 and soon reached a national coverage with 75% of all procedures being entered in 2007. It comprises open and laparoscopic surgery of the gallbladder as well as all endoscopic interventions of the bile ducts. GallRiks is an internet application with on line registration of procedures and follow up as well as electronic reports on demand. A program for validation of data has started and the results from the first 6 hospitals revised indicate a match between the medical records and the database in 98.6% of the cases. During 2006 and 2007 a total of 16400 operations were registered in GallRiks. Patients from hospitals who had registered less than 25 patients were excluded from this study as were patients who had either a major surgery along with the cholecystectomy or only had a choledochotomy (previous cholecystectomy). Incomplete records and cases with a missing 30-day follow up were also excluded. Altogether 747 patients (4.6%) were excluded for these reasons. In another 4726 patients (30%) the surgery was performed acute. Thus, this is a study of 10927 patients who had an elective cholecystectomy performed in 54 Swedish hospitals during the years 2006 and 2007. Results: The 54 hospitals used prophylactic antibiotics at very different rates, from 0% to 98% of the operations, which by far exceeds any random variation. A postoperative abscess was found in 93 (.9%) and in 377 patients (3.5%) some kind of septic complication occurred requiring antibiotic treatment. In a multiple logistic regression analysis, adjusting for age, sex, indications for surgery, surgical methods and operative difficulties peroperative antibiotics had no beneficial effect on the risk of postoperative septic complications. Conclusion: There is a huge variation in the use of prophylactic antibiotics in elective cholecystectomy between different hospitals in Sweden reflecting the lack of uniform guidelines. The rate of septic complications from this operation is low and is furthermore unaffected by prophylactic antibiotics.

640 Transrectal Endoscopic Appendectomy in a Cadaveric Model

Background: Patients operated on for gallstone disease often receive prophylactic antibiotics especially in acute operations but frequently also in elective surgery even though evidence for the effectiveness of such treatment is lacking. In this study we present data on the use of prophylactic antibiotics and postoperative infections from a national, web based register of gallstone surgery. Methods: The Swedish Register for Gallstone Surgery and ERCP (GallRiks) started in May 2005 and soon reached a national coverage with 75% of all procedures being entered in 2007. It comprises open and laparoscopic surgery of the gallbladder as well as all endoscopic interventions of the bile ducts. GallRiks is an internet application with on line registration of procedures and follow up as well as electronic reports on demand. A program for validation of data has started and the results from the first 6 hospitals revised indicate a match between the medical records and the database in 98.6% of the cases. During 2006 and 2007 a total of 16400 operations were registered in GallRiks. Patients from hospitals who had registered less than 25 patients were excluded from this study as were patients who had either a major surgery along with the cholecystectomy or only had a choledochotomy (previous cholecystectomy). Incomplete records and cases with a missing 30-day follow up were also excluded. Altogether 747 patients (4.6%) were excluded for these reasons. In another 4726 patients (30%) the surgery was performed acute. Thus, this is a study of 10927 patients who had an elective cholecystectomy performed in 54 Swedish hospitals during the years 2006 and 2007. Results: The 54 hospitals used prophylactic antibiotics at very different rates, from 0% to 98% of the operations, which by far exceeds any random variation. A postoperative abscess was found in 93 (.9%) and in 377 patients (3.5%) some kind of septic complication occurred requiring antibiotic treatment. In a multiple logistic regression analysis, adjusting for age, sex, indications for surgery, surgical methods and operative difficulties peroperative antibiotics had no beneficial effect on the risk of postoperative septic complications. Conclusion: There is a huge variation in the use of prophylactic antibiotics in elective cholecystectomy between different hospitals in Sweden reflecting the lack of uniform guidelines. The rate of septic complications from this operation is low and is furthermore unaffected by prophylactic antibiotics.