Ankit Patel

Efficacy of Laparoscopic Pyloroplasty for the Treatment of Gastroparesis

BACKGROUND The modest results of nonoperative modalities for the treatment of gastroparesis necessitate greater consideration of surgical therapies. However, the role of surgery is not well defined. The aim of this study is to present our experience with laparoscopic pyloroplasty as early treatment for gastroparesis. STUDY DESIGN Fifty patients with refractory gastroparesis underwent laparoscopic pyloroplasty (hand-sewn Heineke-Mikulicz configuration) from 2006 to 2013 at our institution. Preoperative and postoperative symptom data, gastric emptying scintigraphy, and technical outcomes of the procedure were reviewed. A single-factor ANOVA was performed for the comparison of continuous variables. Results are reported as mean ± SD or median absolute deviation. RESULTS Thirty-four of 50 (68%) patients had previous foregut procedures and/or cholecystectomy. Thirty-two of 50 (64%) patients underwent concomitant procedures (ie, paraesophageal hernia repair and gastrostomy takedown) along with the pyloroplasty. Operative time, including combined procedures, blood loss, and length of stay were 175 ± 56 minutes, 64 ± 50 mL, 2.5 ± 2.7 days, respectively. There were no conversions to open technique or intraoperative complications. There were no suture-line leaks. The readmission rate was 14%. All patients had symptom follow-up and 33 (66%) had postoperative gastric emptying scintigraphy. Postoperative symptom improvement was reported by 82% of the patients (p < 0.001). Median preoperative T1/2 was 180 ± 73 minutes and postoperative T1/2 was 60 ± 23 minutes (p < 0.001). Five patients (10%), who had normalized postoperative T1/2 times, required other gastric emptying procedures; distal gastrectomy (n = 2), duodenojejunostomy (n = 2), and gastric stimulator placement (n = 1). CONCLUSIONS Laparoscopic pyloroplasty is an effective early-treatment modality for selected cases of gastroparesis, with substantial improvement in objective gastric emptying times and low morbidity. The laparoscopic approach does not preclude subsequent procedures when necessary.

Observed Variability in Sleeve Gastrectomy Volume and Compliance Does Not Correlate to Postoperative Outcomes.

Background: Restrictive bariatric procedures reduce gastric capacity as a primary mechanism of action. Intraoperatively, surgeons observe variability in size and compliance of specimens. We hypothesized that higher gastric specimen volume or tissue compliance would respond better to restrictive procedures. Materials and Methods: Consecutive patients undergoing laparoscopic sleeve gastrectomy between September 2012 and September 2013 were enrolled. Specimens were insufflated at graduated pressure points creating pressure volume curves, and compliance was calculated. Postoperative weight loss and a hunger scores were recorded. Correlations were determined by Spearman correlation. Results: Eighty-four patients consented to enrollment. Mean age, weight, and body mass index (BMI) were 45±12 years, 126±23 kg, and 45.4±6 m/kg2, respectively. The resected specimens varied in insufflated capacity from 0.3 to 1.8 (0.71±0.32) L and compliance varied from 14.3 to 85.7 (36.1±14.7) cc/mm Hg. Male patients had a larger greater curvature length (GCL) (P<0.001), staple line length (SLL) (P=0.03), gastric volume (GV) (P=0.002), and gastric compliance (GC) (P<0.001). Neither GV nor GC correlated to excess body weight loss (EBWL%) as hypothesized. There was an inverse correlation between hunger score and GV (P=0.010). The mean 1-month, 3-month, 6-month, and 12-month EBWL was 17.4%, 33.2%, 43.7%, and 54.1%, respectively. Follow-up was 71.4% at 1 month, 39.3% at 3 months, 54.8% at 6 months, and 42.9% at 12 months. Conclusions: Sleeve gastrectomy specimens exhibit nearly 6-fold variability in both volume and compliance. A large GC is anticipated in male and tall subjects. These observations do not appear to be correlated to %EBWL.

Catalysis of ascorbic acid oxidation with peroxynitrite by biomimetic Cu -complexes

Different mononuclear and dinuclear Cu complexes show high catalytic activity at concentrations 1-10 mM in the oxidation of ascorbic acid by peroxynitrite. Their activity is similar to the activity of Mn-porphyrin complexes and weakly depends on ligand environment, provided at least one free coordination site is available. The proposed reaction mechanism involves the intermediate formation of a copper-peroxynitrito complex, which reacts directly with ascorbic acid.

Surgical Technique for Laparoscopic Removal of a Magnetic Lower Esophageal Sphincter Augmentation Device

BACKGROUND Nissen fundoplication is the current gold standard for surgical management of gastroesophageal reflux disease; however, a magnetic antireflux device is now an alternative surgical procedure. The early literature shows good reflux control with minimal complications, and therefore placement of these devices is growing in popularity. As more of these devices are placed, there will be cases in which they will need to be removed. A laparoscopic method for removing the device is presented here. MATERIALS AND METHODS We present a case of a 42-year-old female with history of gastroesophageal reflux who underwent a laparoscopic placement of a magnetic lower esophageal sphincter augmentation device and repair of a small hiatal hernia. She had a complicated postoperative course before presenting to our institution with a 2-year history of persistent dysphagia and requesting the device be removed. Laparoscopic removal of the device was performed. RESULTS After laparoscopic removal of the patients magnetic lower esophageal sphincter augmentation device, she had subjective improvement in her dysphagia but is now being medically managed for gastroesophageal reflux and for delayed gastric emptying. CONCLUSIONS Laparoscopic removal of magnetic lower esophageal sphincter augmentation devices will sometimes be necessary and may be challenging if the surgeon encounters significant scar tissue around the gastroesophageal junction. Postoperative complications are similar to those encountered with foregut surgeries and include postoperative delayed gastric emptying.

The intersection of foregut and bariatric surgeries: treating the whole, not the parts.

QT1 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 In this issue, Perry et al. present their experience of combined laparoscopic repair of paraesophageal hernia (PEH) with Roux-en-Y gastric bypass (RYGB). Repairs of large PEHs continue to be a surgical challenge. Historically, recurrence rates of up to 40% after primary surgical repair have been reported. It is not a coincidence that hiatal hernias of varying sizes can be found on preoperative imaging in 35–40% of morbidly obese patients [1], and performing antireflux surgery alone in patients with a high body mass index (BMI) portends a higher recurrence rate than in patients with a lower BMI [2,3]. Reoperations for recurrences not only increase complications, such as leaks, dysphagia, and vagal nerve trauma, but can lead to more drastic procedures such as gastrectomy [4]. When patients with a high BMI present with a large PEH or severe reflux, the options are to fix the presenting defect and accept the risks of failure and subsequent remedy, or observe and prescribe medications. Neither are great options. Concomitant PEH repair and weight loss procedures in morbidly obese patients present a reasonable solution, because they address the strong association between both diseases. Weight loss surgery is an effective first-line treatment for morbid obesity and is more durable than medical therapy alone. Unfortunately, one of the major barriers is insurance coverage for bariatric procedures. Many insurers have embraced surgical therapy for weight loss, while others exclude these procedures—leaving many obese patients with severe reflux or paraesophageal hernia with a partial option. A significant number of patients we encounter seem to fall in this group. Indeed, it was not until recent years that Medicaid and Medicare approved bariatric surgery for weight loss. Second, referring physicians do not comprehensively address the association of weight problems with reflux or paraesophageal hernias. When patients present to surgeons for repair of their hiatal hernia, but not for weight loss, many are shocked to learn that they are “morbidly obese” and have a high chance of recurrence without drastic and significant weight

Starting and Developing a Robotic Program

There are several views on how to develop and maintain a successful robotics program. Administration may support a program for marketing purposes or oppose one secondary to costs. Many surgeons support having a program for similar reasons, but may struggle to expand the program without further training or maintaining quality across specialties. The purpose of this chapter is not how to start a program, but to focus specifically on maintaining a successful program, especially with training and credentialing. These are the true cornerstones of maintaining quality and ultimately will lead to a successful robotics program. In addition, we will focus on training in an academic setting since the majority of graduating surgical residents and fellows are interested in robotics.

The Background of Robotic Surgery

The history of robotic surgery is fascinating and helps us better understand the evolution of our currently available technologies. Like many advances in surgery, its history is rooted in the US military and was developed to serve and address a special need. Some of these challenges still exist, but evolution in technology and ever-changing consumer demands have framed the current robotic platforms. We will briefly describe these changes in this chapter.

Publication patterns and the impact of self-citation among minimally invasive surgery fellowships

INTRODUCTION The h-index is a widely utilized academic metric that measures both productivity and citation impact. The purpose of this study is to define the impact of self-citation among minimally invasive surgery (MIS) fellowship program directors. METHODS Through the Fellowship Councils website, all program directors and associate program directors from the 148 MIS fellowship programs were identified. Using the Scopus database, we calculated the number of publications, citations, self-citations, and h-index for each surgeon. RESULTS A total of 274 surgeons were identified. The mean number±SD of publications, citations, and h-index for the cohort were 60.5 ± 77.2, 1765 ± 4024, and 16.0 ± 15.0, respectively. The self-citation rate for the entire cohort was 3.23%. Excluding self-citations reduces the mean number of citations to 1708 ± 3887 and h-index to 15.8 ± 14.6. The h-index remained unchanged for 77% (210/274) of surgeons. Only 5% (15/274) of surgeons had a change in h-index of greater than one integer and no surgeon had a change greater than three integers. CONCLUSION Self-citation is infrequent and has a minimal impact on the academic profile of program directors of MIS fellowships.

Biliary reconstruction options for bile duct stricture in patients with prior Roux-en-Y reconstruction

Comprehensive description with illustrations of the 4 biliary reconstruction options for bile duct injury in patients with history of Roux-en-Y gastric bypass.